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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS

 

DIVISION 132

PRIVATE DUTY NURSING SERVICES

410-132-0020

Private Duty Nursing Services

(1) The practice of nursing is governed by the following: Oregon State Board of Nursing, ORS 678.010 to 678.410, and Oregon State Board of Nursing, chapter 851, divisions 031, 045, and 047.

(2) Private duty nursing is considered supportive to the care provided to a client by the client's family, foster parents, and/or delegated caregivers, as applicable. Nursing services must be medically appropriate. Medically appropriate for private duty nursing shift care is determined by qualifying for services based on the Private Duty Nursing Acuity Grid (DMAP 591). Increases or decreases in the level of care and number of hours or visits authorized shall be based on a change in the condition of the client, limitations of the program, and the ability of the family, foster parents, or delegated caregivers to provide care.

(3) The need for private duty nursing shall be established based on a physician's order and the following information:

(a) Nursing assessment;

(b) Nursing care plan;

(c) Documentation of condition and medical appropriateness;

(d) Identified skilled nursing needs;

(e) Goals and objectives of care provided.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 6-1997, f. & cert. ef. 2-19-97; OMAP 6-1999, f. 3-4-99, cert. ef. 4-1-99; OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 54-2002, f. & cert. ef. 10-1-02

410-132-0030

Definitions

(1) Activities of daily living -- Activities usually performed in the course of a normal day in an individual's life such as: eating, dressing, bathing and personal hygiene, mobility, bowel and bladder control, behavior modification, meal preparation, housecleaning, and food acquisition.

(2) Admission -- Acceptance of the client into the private duty nursing program contingent upon meeting the criteria as stated in rule.

(3) Basic tasks of client/nursing care -- Procedures that do not require the education or training of a registered nurse or licensed practical nurse, which cannot be performed by the client independently. Basic tasks of client/nursing care also means procedures that may be directed by the client. These basic tasks include, but are not limited to, activities of daily living. Basic tasks will vary from setting to setting depending on the client population served in that setting and the acuity/complexity of the client's care needs. Basic tasks may require the assignment and supervision of a licensed nurse. The need for supervision is at the discretion of the registered nurse. See State Board of Nursing rules that govern the practice of nursing.

(4) Critical/fluctuating condition -- A situation where the client's clinical and behavioral state is of a serious nature expected to rapidly change and in need of continuous reassessment and evaluation.

(5) Delegation -- A registered nurse authorizes an unlicensed person to perform special tasks of client/nursing care in selected situations and indicates that authorization in writing. Delegation occurs only after assessment of a specific situation (including the ability of the delegate), teaching the task and ensuring supervision. See State Board of Nursing rules that govern the practice of nursing.

(6) Discharge -- Client no longer meets the Division of Medical Assistance Programs (Division) rules and criteria of the private duty nursing program.

(7) Home -- A place of temporary or permanent residence, not including a hospital, ICF/MR, nursing facility, or licensed residential care facility.

(8) Maintenance care -- The level of care needed when the goals and objectives of the care plan are reached, the condition of the client is stable/predictable, the plan of care does not require the skills of a licensed nurse in continuous attendance, or the client, family, foster parents, or caregivers have been taught and have demonstrated the skills and abilities to carry out the plan of care.

(9) Medically Fragile Children's Unit (MFCU) -- A Department of Human Services organizational unit that coordinates and may fund appropriate services for children ages 0 to 18 years with intensive medical needs that require in home and technological supports and meet MFCU criteria.

(10) Member of the household -- Any person sharing a common abode as part of a single family unit, including domestic employees, and others who live together as part of a family unit, but not including a roomer or boarder.

(11) Plan of care -- Written instructions detailing how the client is to be cared for. The plan is initiated by the private duty nurse or nursing agency with input from the prescribing physician. See the "Documentation Requirements" section of the Private Duty Nursing Services administrative rules.

(12) Private duty nursing shift care -- An RN or LPN nursing service for the client's critical/fluctuating conditions requiring the need for reassessment and evaluation with a high probability that complications would arise without skilled nursing management of the treatment program supplied in a specified block of time.

(13) Practice of nursing -- Using the nursing process under doctor's orders to diagnose and treat human response to actual or potential health care problems, health teaching and health counseling, the provision of direct client care and the teaching, delegation and supervision of others who provide tasks of nursing care to clients. See State Board of Nursing rules that govern the practice of nursing.

(14) Private duty nursing visit -- RN or LPN skilled nursing services for non-critical/stable conditions requiring reassessment and evaluation with a moderate probability that complications would arise without skilled nursing management of the treatment program supplied on an intermittent per visit basis.

(15) Respite -- Short-term or intermittent care and supervision in order to provide an interval of rest or relief to family or caregivers.

(16) Responsible unit -- The agency responsible for approving or denying prior authorization.

(17) Shift -- Four to twelve hours of private duty nursing.

(18) Skilled nursing services -- Client care services pertaining to the curative, restorative or preventive aspects of nursing performed by or under the supervision of a registered nurse pursuant to the plan of care established by the physician in consultation with the registered nurse. Skilled nursing emphasizes a high level of nursing direction, observation and skill. The focus of these services must be the use of the nursing process to diagnose and treat human responses to actual or potential health care problems, health teaching, and health counseling. Skilled nursing services include the provision of direct care and the teaching, delegation and supervision of others who provide tasks of nursing care to clients. Such services will comply with the Nurse Practice Act and administrative rules of the Oregon State Board of Nursing, which rules are by this reference made a part of.

(19) Special tasks of client/nursing care -- Tasks that require the education and training of a registered nurse or licensed practical nurse to perform. Special tasks will vary from setting to setting depending on the client population served in that setting and the acuity/complexity of the client's care needs. Examples of special tasks include, but are not limited to, administration of injectable medications, suctioning and complex wound care.

(20) Stable/predictable condition -- A situation in which the client's clinical and behavioral status is known and does not require the regularly scheduled presence and evaluation of a licensed nurse. See State Board of Nursing rules that govern the practice of nursing.

(21) Teaching -- The registered nurse instructs an unlicensed person in the correct method of performing a selected task of client/nursing care. See State Board of Nursing rules that govern the practice of nursing.

(22) Visit -- Nursing service supplied on an intermittent basis in the home.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 6-1997, f. & cert. ef. 2-19-97; OMAP 6-1999, f. 3-4-99, cert. ef. 4-1-99

410-132-0050

Client Copayments

Copayments may be required for certain services. See OAR 410-120-1230 for specific details.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OMAP 86-2002, f. 12-24-02, cert. ef. 1-1-03

410-132-0060

Private Duty Nursing Transition into Maintenance

Private duty nursing services become maintenance care when any one of the following situations occur:

(1) Medical and nursing documentation supports that the condition of the client is stable/predictable.

(2) The plan of care does not require a licensed nurse to be in continuous attendance.

(3) The client, family, foster parents, or caregivers have been taught the nursing services and have demonstrated the skills and ability to carry out the plan of care; or

(4) The combined score on the Acuity Grid and Psychosocial Grid is less than 54.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 9-1991, f. 1-28-91, cert. ef. 3-1-91; HR 6-1997, f. & cert. ef. 2-19-97

410-132-0070

Documentation Requirements

(1) Documentation of services provided is to be maintained in the client's place of residence by the private duty nurse until discharged from service. Payment will not be made for services where the documentation does not support the definition of skilled nursing. Documentation must meet the standards of the Oregon State Board of Nursing.

(2) The private duty nurse must ensure completion and documentation of a comprehensive assessment of the client's capabilities and needs for nursing services within 7 days of admission. Comprehensive assessments must be updated and submitted to the responsible unit by the next work day after any significant change of condition and reviewed at least every 62 days. Some examples of significant change in condition are hospital admission, emergency room visit, change in status, death, or discharge from care.

(3) The nursing care plan must document that the private duty nurse, through case management and coordination with all interdisciplinary staff and agencies, provides services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each client in accordance with a written, dated, nursing care plan:

(a) The nursing care plan must be completed within 7 days after admission. The nursing care plan must be reviewed, updated, and submitted whenever the client's needs change, but at least every 62 days;

(b) The nursing care plan must describe the medical, nursing, and psychosocial needs of the client and how the private duty nurse will actively coordinate and facilitate meeting those needs. This description of needs must include interventions, measurable objectives, goals and time frames in which the goals and objectives will be met and by whom;

(c) The nursing care plan must include the rehabilitation potential including functional limitations related to Activities of Daily Living (ADL), types and frequency of therapies, and activity limitations per physician order;

(d) The nursing care plan must include services related to school-based care according to the Individual Education Plan, if applicable;

(e) The nursing care plan must show coordination of all services being provided, for instance the client or representative, registered nurse (RN) case manager, Department of Human Services (DHS) case worker, physician, other disciplines involved and all other care providers involved in the client's treatment plan;

(f) The nursing care plan must include a statement of the client's potential toward discharge. Timelines must be included in the Plan outline;

(g) The nursing care plan must be available to and followed by all caregivers involved with care of the client.

(4) Documentation of private duty shift care must be written at least every hour on the narrative or flow sheet and must include:

(a) The name of the client on each page of documentation;

(b) The date of service;

(c) Time of start and end of service delivery by each caregiver;

(d) Anything unusual from the standard plan of care must be expanded on the narrative;

(e) Interventions;

(f) Outcomes including clients response to services delivered;

(g) Nursing assessment of client's status and any changes in that status per each working shift; and

(h) Full signature of provider.

(5) Documentation of delegation, teaching and assignment must be in accordance with the Oregon State Board of Nursing Rules.

(6) For documentation to be submitted with prior authorization, see OAR 410-132-0100.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 6-1997, f. & cert. ef. 2-19-97; OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00

410-132-0080

Limitations

(1) General; pertains to both shift care and visits:

(a) Private duty nursing is not covered if the client is:

(A) A resident of a nursing facility;

(B) A resident of a licensed intermediate care facility for people with developmental disabilities;

(C) In a hospital;

(D) In a licensed residential care facility.

(b) Private duty nursing is not covered solely to allow the client's family or caregiver to work or go to school;

(c) Private duty nursing is not covered solely to allow respite for caregivers or client's family;

(d) Payment for private duty nursing will not be authorized for parents, siblings, grandparents, foster care parents, significant others, members of the client's household, or individuals paid by other agencies to provide caregiving services;

(e) Costs of private duty nursing services are not reimbursable if they are provided concurrently with care being provided under home health or hospice program rules;

(f) Home nursing visits as defined in the Home Enteral/Parenteral Nutrition and IV Services rules, are not covered in conjunction with private duty nursing services;

(g) Private duty nursing is not automatically covered in the school setting even if the Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP) indicates the need. The level of need still must be determined by the score on the Private Duty Acuity Grid. All other criteria and limitations must be addressed;

(h) Holidays are paid at the same rate as non-holidays;

(i) Hours nurses spend in training are not reimbursable;

(j) Travel time to reach the job site is not reimbursable;

(k) Maintenance care is not reimbursable.

(2) Private duty nursing visit:

(a) The nursing care plan and documentation supporting the medical appropriateness for private duty nursing must be reviewed every 60 days to continue the service. Reviews must be conducted by the responsible unit;

(b) Private duty nursing visits are limited to two per day.

(3) Private duty nursing shift care:

(a) Medically appropriate private duty nursing shift care for clients up to18 years old, may be covered for acute episodes of illness, injury, or medical condition up to 62 continuous days in cases where it has been determined that skilled management by a licensed nurse is required;

(b) A client may be referred to the Medically Fragile Children's Unit (MFCU), to determine if they meet the criteria for MFCU admission at the time of the initial request for services, on or about day 50 of continuous service, or anytime thereafter (even if it is before the 62nd day) if any of the following are determined to exist:

(A) The client's medical needs are maintenance; or

(B) The client's medical needs are long term.

(c) Private duty nursing shift care for clients age 18 and over will be referred to Aging and People with Disabilities Division (APD) for determination of their long-term care needs;

(d) The number of hours of private duty nursing services that a client may receive is determined by the score on the Private Duty Nursing Acuity Grid (DMAP 591):

(A) Must score greater than 60 points on the Acuity Grid to receive up to 24 hours per day immediately after discharge from a hospital or if there is a significant worsening or decline of condition; or

(B) Must score 50 to 60 points on the Acuity Grid to receive up to 16 hours per day immediately after discharge from a hospital or if there is a significant worsening or decline of condition; or

(C) Must score 40 to 49 points on the Acuity Grid to receive up to 84 hours per week immediately after discharge from a hospital or if there is a significant worsening or decline of condition; or

(D) If the score is 30 to 39 on the Acuity Grid then the Private Duty Nursing Psychosocial Grid (DMAP 590) will be used to determine eligibility. If the score is 24 or above, the client may receive up to 84 hours per week of shift care.

(c) The banking, saving, or accumulating unused prior authorized hours used for the convenience of the family or caregiver is not covered.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 9-1991, f. 1-28-91, cert. ef. 3-1-91; HR 25-1992(Temp), f. & cert. ef. 8-18-92; HR 13-1995, f. 6-2-95, cert. ef. 6-15-95; HR 5-1996, f. & cert. ef. 5-1-96; HR 6-1997, f. & cert. ef. 2-19-97; OMAP 7-1999, f. 3-4-99, cert. ef. 4-1-99; OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 54-2002, f. & cert. ef. 10-1-02

410-132-0100

Prior Authorization

(1) Private duty nursing providers must obtain prior authorization (PA) for all services.

(2) Providers must request PA as follows (see the Private Duty Nursing Services Supplemental Information booklet for contact information):

(a) For Medically Fragile Children’s Unit (MFCU) clients, from the Department of Human Services (Department) MFCU;

(b) For clients enrolled in the fee-for-service (FFS) Medical Case Management (MCM) program, from the MCM contractor;

(c) For clients enrolled in a prepaid health plan (PHP), from the PHP;

(d) For all other clients, from the Division of Medical Assistance Programs.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: PWC 681, f. & ef. 7-17-74; PWC 759, f. 9-5-75, ef. 10-1-75; PWC 799, f. & ef. 6-1-76; AFS 43-1982, f. 4-29-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 9-1983, f. 2-17-83, ef. 3-2-83; AFS 14-1984(Temp), f. & ef. 4-2-84; AFS 22-1984(Temp), f. & ef. 5-1-84; AFS 40-1984, f. 9-18-84, ef. 10-1-84; HR 9-1991, f. 1-28-91, cert. ef. 3-1-91, Renumbered from 461-019-0210; HR 6-1997, f. & cert. ef. 2-19-97; OMAP 7-1999, f. 3-4-99, cert. ef. 4-1-99; OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 93-2003, f. 12-30-03 cert. ef. 1-1-04; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08

410-132-0120

Billing Information

(1) If the client has the Basic Health Care benefit package, but is not enrolled in a prepaid health plan, bill with the appropriate Division of Medical Assistance Programs (Division) unique procedure codes and follow the instructions on how to complete the CMS-1500.

(2) Submit your claim on a CMS-1500, electronically or on paper. Send your paper CMS-1500 to the Division.

(3) For information about electronic billing, contact the Division's Electronic Billing Representative.

(4) When billing for clients with Medicare, bill on a CMS-1500 and enter the appropriate TPR Explanation Code in Field 9.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 9-1991, f. 1-28-91, cert. ef. 3-1-91; HR 6-1997, f. & cert. ef. 2-19-97; OMAP 54-2002, f. & cert. ef. 10-1-02

410-132-0180

Procedure Codes

(1) All private duty nursing services require prior authorization. (See definitions section of the administrative rules).

(2) Private duty nursing visit:

(a) T1030 -- Nursing care, in the home, by registered nurse, per diem;

(b) T1031 -- Nursing care, in the home, by licensed practical nurse, per diem.

(3) Private duty nursing shift care:

(a) S9123 -- Nursing care, in the home, by registered nurse, per hour -- 1 unit equals one hour;

(b) S9124 -- Nursing care, in the home, by licensed practical nurse, per hour -- 1 unit equals one hour.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 9-1991, f. 1-28-91, cert. ef. 3-1-91; HR 6-1997, f. & cert. ef. 2-19-97; OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00; OMAP 54-2002, f. & cert. ef. 10-1-02; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03

410-132-0200

Provider Enrollment

In order for registered nurses or licensed practical nurses to be enrolled or continue enrollment as a Division of Medical Assistance Programs (Division) provider, a copy of licensure must be submitted every two years upon renewal by the Oregon State Board of Nursing.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OMAP 7-1999, f. 3-4-99, cert. ef. 4-1-99; OMAP 16-2000, f. 9-28-00, cert. ef. 10-1-00

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