Private Duty Nursing

PURPOSE: This rule establishes the basis for MO HealthNet enrollment and reimbursement of providers of private duty nursing care for children under Missouri’s Healthy Children and Youth Program. 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 HealthNetenrolled 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. AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2022.* Original rule filed Sept. 2, 1993, effective April 9, 1994. Amended: Filed April 4, 1994, effective Oct. 30, 1994. Amended: Filed Jan. 15, 2004, effective Aug. 30, 2004. Amended: Filed June 1, 2006, effective Dec. 30, 2006. Amended: Filed Dec. 14, 2007, effective June 30, 2008. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. Amended: Filed April 21, 2020, effective Nov. 30, 2020. Amended: Filed Aug. 1, 2022, effective Feb. 28, 2023. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.