25O .0204 - PRIVATE DUTY NURSING

25O .0204. PRIVATE DUTY NURSING

(a) Medically necessary private duty nursing (PDN) services are provided when they are prescribed by a physician and prior approved by the Division of Medical Assistance or its designee.

(b) A patient must reside in the patient's private residence to receive PDN services. Recipients who are in domiciliary care facilities (such as rest homes, group homes, family care homes, and similar settings) and those who are in hospitals, nursing facilities, intermediate care facilities for the mentally retarded, rehabilitation centers, and other institutional settings are not eligible for this service. PDN services are not covered while an individual is being observed or treated in a hospital emergency room or similar environment.

(c) Private duty nursing services are considered medically necessary when the person must require substantial and complex continuous nursing care by a licensed nurse. Professional judgment and a thorough evaluation of the medical complexity and psychosocial needs of the patient are involved in determining the need for PDN. The following situations represent the usual types of cases that may require PDN, though the list is not meant to be all inclusive:

(1) Patient requires prolonged intravenous nutrition or drug therapy with needs beyond those covered by home infusion therapy services.

(2) Patient is dependent on a ventilator for prolonged periods.

(3) Patient is dependent on other device-based respiratory support, including tracheostomy care, suctioning, and oxygen support.

(d) This service is only approvable based on the need for PDN services in the patient's private residence. An individual with a medical condition that necessitates this service normally is unable to leave the home without being accompanied by a licensed nurse and leaving the home requires considerable and taxing effort. An individual may utilize the approved hours of coverage outside of his residence during those hours when the individual's normal life activities take the patient out of the home. The need for nursing care to participate in activities outside of the home is not a basis for authorizing PDN services or expanding the hours needed for PDN services.

(e) A person may not receive Personal Care Services, Skilled Nursing Visits, and Home Health Aide Services reimbursed by Medicaid during the same hours of the day as PDN services.

(f) The patient's spouse, child, parent, grandparent, grandchild, or sibling, including corresponding step and in-law relationship may not be employed by the provider agency when reimbursed by Medicaid to provide PDN services to the patient.

(g) Medicaid payments for PDN are made only to agencies enrolled with the Division of Medical Assistance as providers for the service. An enrolled provider must be a State licensed home care agency located within North Carolina that is approved in its license to provide nursing services.

(Authority G.S. 108A-25(b); 108A-54; 42 C.F.R. 440.80; Eff. May 1, 1990; Amended Eff. April 1, 1993; June 1, 1992; Recodified from 10 NCAC 26B .0121 Eff. October 1, 1993; Recodified from 10 NCAC 26B .0122 Eff. January 1, 1998; Transferred from 10A NCAC 22O .0122 Eff. May 1, 2012.)

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