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Welcome  » March 29, 2024 10:21 AM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Home Health
03/29/2024  

Covered and Noncovered Services : Private Duty Nursing Services

Topic #2025

Daylight Savings Time

Wisconsin Medicaid reimburses only for the number of hours actually worked. Providers who work when daylight savings time ends are still required to adhere to the limitations on authorized services. Nurses are expected to adjust their schedules in advance to accommodate changes in the clock time.

Providers should adhere to the limits on authorized PDN services.

Topic #2096

Emergency Procedures

As required by Wis. Admin. Code § DHS 105.16(10)(e), all agencies providing PDN are required to have the following back-up and emergency procedures in place:

  • Have identified another nurse on the case as a backup to provide services to the member in the event the scheduled nurse is temporarily unable to provide services. Providers are required to inform members of the backup nurse's name before the backup nurse provides services.
  • Have a written plan for member-specific emergency procedures in the case of a life-threatening situation, fire, or severe weather warnings. Home health agencies are required to give this plan to the member and all caregivers prior to the initiation of these procedures.
  • Take appropriate action in the case of any significant accident, injury, or adverse change in the member's condition. Nurses are required to immediately notify the member's physician, guardian (if any), and any other responsible person designated in writing by the member or member's legal representative.
Topic #13958

Managing Authorized Units Within 13-Week Segments

Unused hours authorized for one 13-week segment do not carry over to another 13-week segment. If the member's condition changes and more hours will be needed to provide medically necessary services, the POC needs to be updated and reviewed, signed, and dated by the attending physician. If the change in condition is temporary and PRN hours are needed, then the physician orders must specify the dates when additional medically necessary services are to begin and end. To obtain PA for medically necessary PRN hours, the PAL is required to submit an amendment request. Pro re nata hours will not be authorized for any 13-week segment that is authorized for flexible use of hours.

Topic #2092

Member Eligibility for Services

According to Wis. Admin. Code § DHS 107.12(1)(a), a member is eligible for PDN services if they:

  • Require a total of eight or more hours of direct skilled nursing services in a 24-hour period according to the POC.
  • Do not reside in a hospital or nursing facility.
  • Have a written POC specifying the medical necessity for PDN services.

Ventilator-Dependent Members

In accordance with Wis. Admin. Code § DHS 107.113(1), a ventilator-dependent member is eligible for respiratory care when they meet all of the criteria for PDN services and meet the following requirements:

  • Are medically dependent on a ventilator for life support at least six hours per day. In addition, the member is required to meet one of the following two conditions:
    • Has been hospitalized for at least 30 consecutive days for their respiratory condition. The 30 consecutive days may occur in more than one hospital or nursing facility.
    • If they have been hospitalized for less than 30 days, their enrollment for services will be determined by the DMS Chief Medical Officer on a case-by-case basis. The Chief Medical Officer's determination may include discussions with the member's pulmonologist and/or primary care physician to evaluate the member's diagnosis, prognosis, history of hospitalizations for the respiratory condition, and weaning attempts, when appropriate.
  • Has adequate social support to be treated at home and desires to be treated at home.
  • May have ventilator care safely provided at home.
Topic #2091

Member Medical Record

Home health agencies are required to maintain a medical record for each member receiving PDN services as stated in Wis. Admin. Code § DHS 105.16(10)(d). The record must document the nature and scope of all services provided and be systematically organized and readily accessible to ForwardHealth. The medical record must include all of the following:

  • Member identification information.
  • The member's condition, problems, progress, and all services rendered.
  • Appropriate hospital information supplied by the hospital, including discharge information, diagnosis, current patient status, and post-discharge POC.
  • An admission evaluation and assessment of the member.
  • All medical orders, including the current physician written POC and all interim physician's orders. The Plan of Care chapter contains further information about a physician's verbal orders.
  • A consolidated list of medications, including start and stop dates, dosage, route of administration, and frequency. This list must be reviewed and updated for each nursing visit, if necessary.
  • Progress notes posted as frequently as necessary to clearly and accurately document the member's status and services provided. A "progress note" is a written notation, timed, dated, and signed by a member of the health team providing covered services, that summarizes facts about the care furnished and the member's response during a given period of time.
  • Clinical notes written, timed, signed, and dated the day service is provided and incorporated into the medical record within seven days. A copy of these notes should be maintained in the record in the member's home. These notes are a notation of contact with a member that document the PDN services provided and should do the following:
    • Describe the member's medical status, including signs and symptoms.
    • List the time and date of the contact, a description of treatment and drugs administered, and the member's reaction.
    • Describe any changes in the member's physical or emotional condition and any nursing intervention.
    • Nurses are encouraged to write clinical notes as services are provided and complete them by the end of each shift. These notes should be utilized by nurses performing services during subsequent shifts in order to maintain continuity of care.

  • Written summaries of the member's care provided by the nurse to the physician at least every 62 days.

The following information must be included in the documentation concurrent to the notation of service in both progress notes and clinical notes:

  • The date and time of service.
  • The signature and title of the rendering provider.

All physician-ordered treatments and interventions included in the POC must be documented in the member's medical record.

For ventilator-dependent members, the ventilator settings, parameters, and the ventilator checks must also be documented in the member's medical record at least for each nurses' shift.

The results of each supervisory visit must be documented in the member's medical record.

Topic #4897

Members with Changing Nursing Needs

During a member's course of treatment, the number of hours of nursing services they require may change. As a result, the member may transition from home health services to PDN services or the member may no longer require PDN services. When a change in the level of service occurs, ForwardHealth requires notification to end the PA. If the member's needs change from PDN to home health services, the home health provider is required to submit a new PA request to Wisconsin Medicaid.

Members Changing to Private Duty Nursing

If the condition of a member receiving home health skilled nursing services changes to the point that eight or more hours of direct, skilled nursing care are required in a calendar day, the member is no longer eligible for home health skilled nursing services. For reimbursement of covered PDN services, ForwardHealth must authorize PDN services for the member.

Topic #2095

Place of Service

As stated in Wis. Admin. Code § DHS 107.12(1)(a), members who are authorized to receive PDN services in the home may make use of approved hours of service outside the home setting during those hours when a member's normal life activities take them outside the home setting.

Topic #2094

Providers of Services

Only RNs and LPNs can provide PDN. The following PDN services can only be performed by an RN:

  • The initial evaluation visit.
  • Initiating the physician's POC and any necessary revisions.
  • Providing those services that require the care of an RN as defined in Wis. Admin Code § ch. N 6.
  • Initiating appropriate preventive and rehabilitative procedures.
  • Regularly evaluating the member's needs.
  • Acting as the PDN PAL.

Nursing services not requiring an RN may be provided by an LPN under the supervision of an RN. An LPN's duties include the following:

  • Performing nursing acts delegated by an RN under Wis. Admin. Code § ch. N 6.03.
  • Assisting the member in learning appropriate self-care techniques.
  • Meeting the nursing needs of the member according to the written POC. All nursing acts performed must be within the professional scope of practice for the LPN.

In accordance with Wis. Admin. Code § DHS 105.16(10)(a)3, both RNs and LPNs are required to do the following:

  • Arrange for or provide health care counseling within the scope of nursing practice to the member and the member's family in meeting the needs related to the member's condition.
  • Provide coordination of care for the member, including ensuring that provision is made for all required hours of care for the member.
  • Accept only those delegated medical acts for which there are written or verbal orders and for which the nurse has appropriate training or experience.
  • Within 24 hours of providing service, prepare written clinical notes that document the care provided and incorporate them into the member's medical record within seven days.
  • Promptly inform the physician and other personnel participating in the member's care of changes in the member's condition and needs.

Ventilator-Dependent Members

Only RNs and LPNs may provide PDN services to ventilator-dependent members. The provider is required to document that the appropriate home health agency staff are qualified to perform all of the following services:

  • Tracheostomy care. Stoma care, suctioning, humidification, changing a tracheostomy tube, and emergency procedures for tracheostomy care.
  • Oxygen therapy. Operation of oxygen systems and auxiliary oxygen devices, and written documentation of the member's oxygen needs.
  • Operation and interpretation of monitoring devices. Types of cardio-respiratory monitoring, pulse oximetry, and capnography.
  • Operation of ventilators. Positive pressure or negative pressure ventilation.
  • Other respiratory therapies. Continuous positive airway pressure, chest physiotherapy, respiratory assessment, and operation of aerosol and humidity devices.
  • Pulmonary rehabilitation. Maintenance and restoration of the member's physical functioning, modification of the member's immediate living environment, assessment of the member's activities of daily living.
Topic #2093

Qualifying Hours of Care

To determine if a member receives eight or more hours of direct skilled nursing services, add up the total hours of direct skilled nursing care provided by all caregivers, including home health agencies, independent nurses, and skilled cares provided by family or friends. If the total time required daily for these cares is equivalent to eight or more hours, the member is eligible for PDN. The POC is required to include the actual amount of time to be spent on medically necessary direct cares that require the skills of a licensed nurse.

For this purpose, ForwardHealth-covered skilled nursing services may include, but are not limited to, the following:

  • Injections
  • Intravenous feedings
  • Gastrostomy feedings (include the time needed to begin, disconnect, and flush — not the entire time the feeding is dispensing)
  • Nasopharyngeal and tracheostomy suctioning
  • Insertion and sterile irrigation of catheters
  • Application of dressings involving prescription medications and aseptic techniques
  • Treatment of extensive decubitus ulcers or other widespread skin disorders

Reasonable time for record keeping, travel, staff training, supervision, and case management are allowable costs that have been included in the rates established for PDN hours. Therefore, the time spent on these activities is not separately reimbursable.

If the member requires fewer than eight hours of direct skilled nursing services in a 24-hour period, they may be eligible for home health skilled nursing services. A member cannot be concurrently enrolled for both PDN and intermittent part-time skilled visits provided by nurses.

Topic #2090

Reimbursement Requirements

Wisconsin Medicaid reimburses PDN services as part of the PDN benefit if the services:

  • Meet the criteria to be classified as PDN services.
  • Are prior authorized.
  • Are prescribed by a physician in accordance with Wis. Stat § 49.46(2).
  • Are provided to members enrolled under Wis. Stat § 49.47(6)(a).
  • Are implemented according to Wis. Admin. Code ch. DHS 107.
  • Are provided in accordance with the member's POC. Services provided to the member that are not on the POC are not covered services.
Topic #8598

Work Hour Limitations

The nurse providing PDN and/or PDN-Vent may not provide nursing service in excess of 12 hours in a calendar day and 60 hours in a calendar week to all members and other patients under the nurse's care, as stated in Wis. Admin. Code §§ DHS 107.113(5)(d), and 107.12(4)(f) and (g).

The nurse is also required to take at least eight continuous and uninterrupted hours off duty in any 24-hour period during which they perform PDN and/or PDN-Vent services that are reimbursed by Wisconsin Medicaid, as stated in Wis. Admin. Code §§ DHS 107.12(4)(g) and 107.113(5)(g).

PDN and/or PDN-Vent services provided in excess of the calendar day and calendar week limits are not covered. Services provided when the nurse does not meet the off-duty requirements are also considered noncovered services.

Definitions for a Calendar Day and a Calendar Week

The following definitions are applicable to PDN and to PDN-Vent:

  • A 24-hour period should not be confused with a calendar day. For the purpose of ForwardHealth PDN services, each calendar day is a 24-hour period that begins at midnight and ends at midnight.
  • A calendar week begins with Sunday, ends with Saturday, and consists of seven consecutive calendar days.
  • A 24-hour period consists of 24 consecutive hours and should not be confused with a calendar day.

Note: Exceptions to these rules may exist in extremely rare circumstances. Requests for exceptions should be made in writing to:

ForwardHealth Home Care Analyst
Division of Medicaid Services
Rm 350
1 West Wilson St
Madison WI 53703
 
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