13 CSR 70-95.010 - Private Duty Nursing
PUBLISHER'S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.
(1) Service Definition. Private duty nursing
is the provision of individual and continuous care (in contrast to part-time or
intermittent care) under the direction of the participant's, physician, by
licensed nurses acting within the scope of the Missouri Nurse Practice Act.
Services within the MO HealthNet private duty nursing program include:
(A) Shift care by a registered nurse (RN);
and
(B) Shift care by a licensed
practical nurse (LPN).
(2) Persons Eligible for Private Duty Nursing
Care. MO HealthNet-eligible children under the age of twenty-one (21) may be
eligible for private duty nursing care under the Healthy Children and Youth
Program (HCY) when there is a medical need for a constant level of care,
exceeding the family's ability to independently care for the child at home on a
long-term basis without the assistance of at least a four- (4-) hour shift of
home nursing care per day. Private duty nursing services for children are prior
authorized by the Bureau of Special Health Care Needs of the Department of
Health and Senior Services.
(3)
Criteria for Providers of Private Duty Nursing Care for Children.
(A) A provider of private duty nursing care
must have a valid MO HealthNet Private Duty Nursing Provider Agreement in
effect with the Department of Social Services, Missouri Medicaid Audit and
Compliance Unit (MMAC). To enroll, the applicant must be a Medicare-certified
and MO HealthNet-enrolled home health agency, or be accredited by Joint
Commission for Accreditation of Health Organization (JCAHO), or be accredited
by Community Health Accreditation Partner (CHAP), or submit a Private Duty
Nursing Provider Agreement Addendum to MMAC Provider Enrollment.
(4) Administrative Requirements
for Private Duty Nursing Providers.
(A) The
provider shall immediately notify the MMAC of any change in location, telephone
number, or administrative or corporate status. A thirty- (30-) day written
notice to the MMAC will be required of the provider prior to the voluntary
termination of the provider agreement.
(B) The provider shall maintain bonding,
personal and property liability, and medical malpractice insurance coverage on
all employees involved in delivering nurse service in the home.
(C) The provider must have the capability to
provide nursing staff outside of regular business hours, on weekends and on
holidays to provide services in accordance with the plan of care authorized by
the Bureau of Special Health Care Needs for each client.
(D) The provider must have a policy for
responding to emergency situations. Services reimbursed by MO HealthNet may not
exceed the prior authorization approved by the Bureau of Special Health Care
Needs, therefore, any emergency situation resulting in service delivery beyond
the limits of the prior authorization must be reported in writing to the Bureau
of Special Health Care Needs within seventy-two (72) hours.
(E) The provider shall have a written
statement of the participant's Bill of Rights, which shall be given to the
caretaker (if the participant is a minor) at the time the service is
initiated.
(F) The provider shall
have a written grievance policy which shall be provided to each participant or
caretaker upon initiation of services. The grievance policy must also include
the phone number of the Bureau of Special Health Care Needs and the MO
HealthNet Division.
(G) The
provider must report all instances of possible child abuse or neglect to the
Child Abuse and Neglect (CA/N) Hotline, 1-800-392-3738. Any suspected abuse or
neglect by a caretaker, including private duty nursing staff, must be reported
according to 210.110-210.189, RSMo, the Child Abuse Law. Failure to report by a
mandatory reporter (private duty nursing staff would be considered mandatory
reporters) is a violation of 210.115, RSMo, and could be subject to
prosecution.
(H) The provider must
maintain Missouri Corporate Good Standing status with the Office of the
Missouri Secretary of State.
(5) Qualification Requirements for Private
Duty Nursing Direct Care Staff and Supervisors.
(A) For nursing staff, the provider agency
shall show evidence in the personnel record that the employee's licensure
status with the Missouri Board of Nursing is current.
(B) Upon initial employment, the provider
shall document that at least two (2) employment or personal references (not to
include relatives) were contacted prior to that employee delivering direct care
services.
(C) The provider will be
responsible for assuring and documenting that the nurse's health permits
performance of the required activities and does not pose a health hazard.
Service delivery shall be prohibited when the employee has a communicable
condition.
(6)
Requirements for Training for Private Duty Staff.
(A) All direct care staff (LPNs and RNs) must
have at least four (4) hours of orientation training prior to service
provision. Orientation training should include general information about the MO
HealthNet Private Duty Nursing Program, the HCY program, relationship of the
provider agency with the MO HealthNet Division and the Bureau of Special Health
Care Needs, the prior authorization process, child abuse/neglect indicators and
reporting, participant rights, participant grievance procedures, internal
agency policy, and a review of universal precaution procedures as defined by
the Center for Disease Control.
(B)
Prior to delivering services, LPNs must demonstrate competency in each task
required by the plan of care. The competency demonstration must be conducted by
an RN and must be documented in the LPN's personnel file.
(C) All direct care staff must have a
certificate in either cardiopulmonary resuscitation (CPR) or basic certified
lifesupport (BCL).
(7)
Requirements for Supervision of Private Duty Nursing Staff.
(A) Each agency shall employ an RN, with
three (3) years' nursing (RN and/or LPN) experience, to act as supervisor to
all other nursing staff. One (1) year of experience must either be in
supervisory position or in the field of pediatric nursing. The RN supervisor
will be responsible for case conferences with staff nurses and documenting the
conferences, assuring the competency of staff, training and orientation, and
evaluation of direct care staff. An LPN with three (3) years' experience may
act as the assistant supervisor under the RN supervisor. One (1) year of
experience must be in high acuity pediatric nursing care in a hospital, home
care agency, or residential setting. The assistant nursing supervisor may be
responsible for case conferences with staff nurses, documenting the
conferences, developing plan of care after the initial plan of care has been
established by an RN, orientation, training, and evaluation of direct care
staff and other duties delegated by the nursing supervisor.
(B) All nursing staff providing direct care
shall have an annual performance evaluation completed by a licensed nurse
supervisor, maintained in the personnel record.
(C) Frequency of supervisory visits.
1. Participants of private duty nursing care
shall have a personal visit with assessment by a licensed nurse supervisor at
least once every sixty (60) days if the participant is authorized for LPN
service. Supervisory visits by a nurse will not be separately
reimbursed.
2. Patients who have
received RN shift care through the Private Duty Nurse Program or intermittent
visits by an RN under the home health program (if those services were provided
by an agency affiliated with the private duty provider) are not required to
have a separate supervisory visit.
3. Supervisory visits, or explanation of why
there are no separate supervisory visits for the month (that is, RN shifts were
delivered), are to be documented in the participant record.
(8) Requirements for the
Contents of Medical Records. Appropriate medical records for each MO HealthNet
participant served must be maintained at the private duty nursing agency.
Records shall be kept confidential and access shall be limited to private duty
nursing staff and representatives of the Departments of Social Services and
Health and Senior Services.
(A) Medical
records shall contain the following:
1.
Identifying information about the participant, such as name, birthdate, MO
HealthNet participant identification number, caretaker, and emergency contact
person;
2. All forms or
correspondence to and from the Bureau of Special Health Care Needs regarding
the services which have been prior authorized;
3. Signed orders, under the direction of the
participant's physician, prior to service delivery which must be updated each
time the prior authorization is due for approval by the Bureau of Special
Health Care Needs;
4. Consent from
the child's legal custodian for treatment prior to service delivery;
5. The plan of care, documenting the amount,
duration, and scope of the service. The level of care indicated in the plan of
care (RN or LPN) must be based on acceptable standards of nursing practice.
Reimbursement is based on the prior authorization approved by the Bureau of
Special Health Care Needs, with that prior authorization based upon the plan of
care, specifying the number of units and the skill level of the service, for
periods of up to six (6) months;
6.
Daily documentation of all services provided and any supervisory
visits;
7. Documentation of the
LPN's competency demonstration before an RN when the plan of care includes the
services of an LPN as required in subsection (6)(B); and
8. Documentation that a copy of the
participant's Bill of Rights was given to the participant, parent, or
guardian.
(9)
Reimbursement.
(A) Payment will be made in
accordance with the fee per unit of service as defined and determined by the MO
HealthNet Division.
1. A unit of service is
fifteen (15) minutes.
2. The fee
per unit of service will be based on the determination by the state agency of
the reasonable cost of providing the covered services on a statewide basis and
within the mandatory maximum payment limitations.
3. Payment will be made on the lower of the
established rate per service unit or the provider's billed charges. The charge
billed to MO HealthNet may not be more than a provider's ordinary charge to the
general public for the same services.
(B) Conditions for Reimbursement.
1. Services will be authorized by the Bureau
of Special Health Care Needs prior to delivery, in accordance with a private
duty nursing care plan, specifying the amount, duration, and scope of services.
The prior authorization will be the basis for reimbursement.
2. A MO HealthNet Division enrolled PDN
agency may be reimbursed for PDN services rendered by a legal guardian or
family member. A family member is defined as a parent; sibling; child by blood,
adoption, or marriage; spouse; grandparent or grandchild. The PDN caregiver who
delivers the direct care must have a valid RN or LPN license in the State of
Missouri and be employed by the MO HealthNet Division enrolled PDN
provider.
3. PDN services provided
by a family member or legal guardian for a single participant or multiple
participants with the same residence may not exceed twelve (12) hours per day
up to a maximum of forty (40) hours per week. A family member or legal guardian
shall not provide more than forty (40) hours of service in a seven- (7-) day
period. For a family member or legal guardian, forty (40) hours is the total
amount allowed regardless of the number of children who receive
services.
(10)
MO HealthNet Private Duty Nursing Provider Manual. The Department of Social
Services, MO HealthNet Division, shall administer the MO HealthNet Private Duty
Nursing program. The services covered and not covered, the program limitations,
and the maximum allowable fees for all covered services shall be included in
the Private Duty Nursing provider manual, which is incorporated by reference
and made a part of this rule as published by the Department of Social Services,
MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its
website at http://manuals.momed.com/collections/collection_pdn/print.pdf,
August 1, 2022. This rule does not incorporate any subsequent amendments or
additions.
Notes
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No prior version found.