Current through Register Vol.. 38, No. 17, April 11, 2022
A. Service description. Private duty nursing
(PDN) service means individual and continuous nursing care that shall be
provided due to the intensity of medical supports required by individuals who
have complex health care needs that have been certified by a physician as
medically necessary to enable the individual to remain at home rather than in a
hospital, nursing facility, or ICF/IID.. PDN shall be provided on a one-to-one
basis, and cannot be provided concurrently with skilled nursing services,
personal assistance services, respite services, or companion services.
Individuals receiving PDN services shall not be authorized for skilled nursing
services except in the case of nurse delegation responsibility activities. PDN
shall support and not replace caregiver responsibilities. PDN service shall be
covered in the FIS and CL waivers.
Criteria and allowable activities.
1. The individual shall require PDN service
that has been certified by a Virginia-licensed physician as medically necessary
to enable the individual to remain at home or otherwise in the community rather
than in a hospital, a nursing facility, an ICF/IID, or any other type of
2. The medical
necessity for PDN service shall be documented in the individual's ISP. Once the
medical necessity can no longer be demonstrated, this service shall be
a. On-going monitoring of an
individual's medical status as it relates to the specified medical and nursing
b. Administering medications
or other medical treatment; and
Assistance with ADLs in conjunction with medical treatment and care.
d. Training for family or other caregivers in
relation to those activities that are part of the nursing plan for supports.
units and limits.
1. The unit of service
shall be a quarter hour.
Individuals enrolled in the waiver shall not be authorized to receive private
duty nursing service and skilled nursing service.
3. Private duty nursing service shall not be
covered under the waiver if the individual who is younger than 21 years of age
is eligible for private duty nursing service covered through Medicaid's Early
and Periodic Screening, Diagnosis and Treatment program.
2. Private duty nursing service may be
provided by either (i) a licensed RN or (ii) licensed LPN who is under the
supervision of a licensed RN. The licensed RN or LPN shall be employed by a
DMAS-enrolled home health provider or contracted with or employed by a
DBHDS-licensed day support service, respite service, or residential service
3. Both RNs and LPNs
providing private duty nursing service shall have current licenses issued by
the Virginia Board of Nursing or hold current multistate licensure privileges
to practice nursing in the Commonwealth.
Service documentation and requirements.
Providers shall include signed and dated
documentation of the following in each individual's record:
A copy of the completed, standard,
age-appropriate assessment form as described in 12VAC30-122-200
The provider's plan for supports per
requirements detailed in 12VAC30-122-120
and the CMS 485.
c. Documentation of all training, including
the dates and times provided to family/caregivers or staff, or both, including
the person being trained and the content of the training.
d. Documentation that the RN and LPN has the
experience or skills necessary to perform the tasks as ordered by the physician
included in the plan for supports.
e. Documentation of nursing licenses,
qualifications of providers, and physician's orders done every six
f. Documentation of the
physician's determination of medical necessity prior to service being
summarizing interventions, results of treatment, the dates and times of nursing
interventions that are provided, and the amount and type of service.
h. A review of the supporting documentation
with the individual or his family/caregiver, as appropriate, and documentation
that shows a written summary of this review was submitted to the support
coordinator/case manager at least quarterly with the plan for supports modified
as appropriate. For the annual review and anytime supporting documentation is
updated, the supporting documentation shall be reviewed with the individual or
his family/caregiver, as appropriate, and such review shall be documented.
i. All correspondence to the
individual and the individual's family/caregiver, as appropriate, the support
coordinator, DMAS, and DBHDS.
Written documentation of all contacts with the individual's family/caregiver,
physicians, providers, and all professionals regarding the
documentation shall support all claims submitted for DMAS reimbursement. Claims
for payment that are not supported by supporting documentation shall be subject
to recovery by DMAS or its designee as a result of utilization reviews or