28 January 2000 GST/HST Interpretation 5895 - Foot Care Services Provided by Nurses

Dear Sir:

This is in reply to your letter of December 14, 1999 sent to the XXXXX XXXXX concerning the application of the Goods and Services Tax (GST)/Harmonized Sales Tax (HST) to foot care services provided by XXXXX XXXXX using the services of Registered Nurses ("RNs") and Licensed Practical Nurses ("LPNs").

Please note that as of November 1, 1999, Revenue Canada became the Canada Customs and Revenue Agency (the "CCRA").

Inte[r]pretation Requested

XXXXX provides the services of RNs and LPNs for the management of lower limb pathology, for the restoration of health, and for the prevention of lower limb complications associated with diseases including, but not limited to, diabetes, peripherial vascular disease, arthritis, and multiple sclerosis. It is your view that the foot care services provided by the RNs and LPNs qualify as exempt nursing services for the purposes of the GST/HST. On the basis of the information provided in your letter, our understanding of the services supplied by XXXXX is as follows:

1[.] The RNs and LPNs treat lower limb health problems such as onychogryphotic (Rams horn nail) and onychomycotic nails (fungal nail infections), and hyperkeratoses (corns) secondary to foot and gait dysfunction.

2[.] The RN is responsible for complicated lower limb care and for treatments prescribed by physicians (i.e., medical practitioners) such as wound dressing changes, diabetic ulcer debridement, and the application of compression therapy.

3[.] The foot care services are delivered at various locations including the client's residence, personal care homes, and in hospitals.

4[.] Approximately 50% to 60% of the caseload of XXXXX is initiated by a physician whereby the physician arranges for the services of XXXXX for his or her patient. A client health care file is maintained, a care plan is established, and contact with a physician is initiated. For the remaining cases, the client's physician is contacted regarding the client's medical needs and to discuss a care plan.

5[.] The foot care services provided by XXXXX are not paid for or reimbursed by the XXXXX[.]

Interpretation Given

The term "nursing service" is not defined in the ETA. Therefore, only those services that have been traditionally viewed as nursing services qualify as such for the purposes of the exemption provided in section 6 of Part II of Schedule V to the ETA. Accordingly, nursing services are viewed as patient care services that pertain to the curative, restorative, and preventative aspects of nursing that are rendered by a registered nurse, registered nursing assistant, a licensed or registered practical nurse, or a registered psychiatric nurse. Nursing services include personal care, administration of drugs and other medications (usually on the order of a medical practitioner), assessment of a patient's needs and requirements, and the preparation of care plans for the individual patient. Additional conditions are placed on these services for the purposes of this provision which restricts the exemption only to those services:

(a) rendered to an individual in a health care facility or in the individual's place of residence;

(b) that are private-duty nursing services; or

(c) supplied to a public sector body.

A "health care facility" is defined in section 1 of Part II of Schedule V to the ETA to include hospitals as well as residential facilities that provide nursing and personal care under the direction or supervision of qualified medical and nursing care staff or other personal and supervisory care according to the individual requirements of the residents, assistance with daily living, social, recreational, and other related services to meet the psycho-social needs of the residents, and meals and accommodation. Consequently, personal care homes may be considered to be health care facilities for the purposes of the ETA.

For the purposes of the ETA, a traditional nursing service does not include a foot care service. Nurses are not medically trained health care professionals who specialize in treating disorders of the foot and lower limb. Serious foot conditions require the attention of a medical practitioner or a podiatrist or chiropodist. The foot care that a nurse can provide is limited in scope, e.g., basic preventative health care for the skin and nails, and this care is only one component of total nursing care.

It is our understanding, however, that when a nurse, e.g., RN or LPN, renders foot care to individuals who have diabetes, peripheral vascular disease and strokes, the foot care is provided under the direction of a medical practitioner. It is the CCRA's view that where an RN or LPN renders foot care services to a patient under the direction of a medical practitioner, such care is part of the continuum of health care for the individual and as such, is a nursing service for the purposes of the exemption provided in section 6 of Part II of Schedule V to the ETA where the service is provided in a health care facility or the patient's place of residence.

Nursing services (other than private-duty nursing services or nursing services supplied to a public sector body) provided in a place other than a health care facility or the patient's place of residence do not satisfy the conditions of section 6 of Part II of Schedule V to the ETA. Thus, nursing services provided in a foot care clinic are not exempt under this provision and as no other exempting provision applies, this supply is subject to the GST/HST at the rate of 7% (or the rate of 15% in the participating provinces of Newfoundland, Nova Scotia and New Brunswick).

Foot care services that are not supplied under the direction of a medical practitioner are not exempt under section 6 of Part II of Schedule V to the ETA. As previously stated, a supply of a foot care service itself is not viewed as a nursing service for the purposes of the ETA. Therefore, when an individual, on his or own accord, contracts with a nurse or a clinic for foot care services, the individual is not contracting for a nursing service. Furthermore, as the foot care services are not provided under the direction of a medical practitioner, the provision of these services is not part of the continuum of health care for the individual. Consequently, foot care services supplied by nurses in these circumstances are subject to tax regardless of where the services are provided, e.g., in the individual's home, a personal care home, a foot care clinic, or in a health care facility.

Please note that a "nursing practice" does not have the same meaning as a "nursing service rendered" for the purposes of the ETA, nor does "health care service" equal "nursing service." For instance, paramedical services are taxable for ETA purposes, even when these services are provided by a nurse. Furthermore, other health care services, such as those listed in section 7 of Part II of Schedule V, will not be exempt under section 6 of that Part because the nurse is not a licensed practitioner of the service. Thus, even when services such as chiropodic or podiatric services are recognized under the standards of practice provided by a nursing regulatory body, such services are not necessarily nursing services for ETA purposes.

The foregoing comments represent our general views with respect to the subject matter of your letter. Proposed amendments to the ETA, if enacted, could have an effect on the interpretation provided herein. These comments are not rulings and, in accordance with the guidelines set out in section 1.4 of Chapter 1 of the GST/HST Memoranda Series, do not bind the CCRA with respect to a particular situation.

Should you have any further questions or require clarification on the above matter, please do not hesitate to contact me at (613) 952-6761.

Yours truly,

Susan Eastman
Municipalities and Health Care Services Unit
Public Service Bodies and Governments Division