12 Va. Admin. Code § 30-50-132

Current through Register Vol. 41, No. 9, December 16, 2024

Section 12VAC30-50-132 - [Effective until 4/5/2025] Private duty nursing services under early and periodic screening, diagnostic, and treatment

A. This section applies to private duty nursing services for eligible individuals in fee-for-service programs. Individuals enrolled with managed care health plans receive private duty nursing services through their plans.

B. Service description. Private duty nursing services are individualized, medically necessary nursing care services consisting of skilled interventions, assessment, monitoring, and teaching of those who are or will be involved in nursing care for the individual. Private duty nursing services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit are provided when appropriate and medically necessary to correct and ameliorate a member's health conditions. As opposed to intermittent care provided under skilled nursing or home health nursing, private duty nursing is provided on a continuous or regularly scheduled basis according to medical necessity. Private duty nursing care provided can be based in the individual's home or any setting in which normal life activities take place. Congregate private duty nursing is defined as private duty nursing provided to two or more individuals who require private duty nursing in the same setting. Services are provided in accordance with 42 CFR 440.80.

C. Service components. Private duty nursing service is the management and administration of the treatment and care of an individual by a licensed nurse, within the scope of practice as outlined by the Virginia Board of Nursing. Private duty nursing service is not limited to:

1. Assessments (e.g., respiratory assessment, patency of airway, vital signs, feeding assessment, seizure activity, hydration, level of consciousness, constant observation for comfort and pain management);

2. Administration of treatment related to technological dependence (e.g., ventilator, tracheotomy, bi-level positive airway pressure (BiPAP), intravenous (IV) administration of medications and fluids, feeding pumps, nasal stints, central lines);

3. Monitoring and maintaining parameters or machinery (e.g., oximetry, blood pressure, lab draws, end tidal CO₂s, ventilator and tube feeding pumps);

4. Interventions (e.g., medications, suctioning, IVs, hyper alimentation, enteral feeds, ostomy care, tracheostomy care); and

5. Exclusions from Department of Medical Assistance Services (DMAS) coverage of private duty nursing services include the following:

a. Not custodial or personal care delivered for the purpose of helping with activities of daily living (ADLs), including dressing, feeding, bathing, or transferring from a bed to a chair, and that can safely and effectively be performed by trained nonmedical personnel;

b. Monitoring for medically-controlled disorders as part of "maintenance of care"; and

c. Respite services.

D. Provider qualifications.

1. Private duty nursing providers shall meet the following requirements:

a. Operate from a business office;

b. Disclose ownership, if requested; and

c. Attest to the ability to document and maintain individual case records in accordance with state and federal requirements.

2. Private duty nursing must be provided by a registered nurse (RN) or licensed practical nurse (LPN) employed by (or subcontracted with) and supervised by a private duty nursing provider enrolled with DMAS.

a. The RN private duty nurse must possess the following qualifications:

(1) A license to practice in the Commonwealth of Virginia; and

(2) A satisfactory work history as evidenced by two satisfactory reference checks from prior job experience, including no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children, recorded in the nurse's personnel file. If the RN has worked for a single employer, one satisfactory reference from a prior job experience and one personal reference both with no evidence of abuse, neglect, or exploitation of an incapacitated or older adults or children is acceptable, and the RN private duty nurse shall submit to a criminal record check obtained through the Virginia State Police. If the individual receiving services is a minor, the RN must also submit to a search of the Virginia Department of Social Services (VDSS) Child Protective (CPS) Central Registry. The provider shall not hire any RN with findings of barrier crimes identified in § 32.1-162.9:1 of the Code of Virginia or founded complaints in the VDSS CPS Central Registry.

b. A licensed practical nurse (LPN) shall meet the following requirements:

(1) Be licensed to practice in the Commonwealth of Virginia;

(2) Have a satisfactory work history as evidenced by two satisfactory reference checks from prior job experience, including no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children, recorded in the nurse's personnel file. If the LPN has worked for a single employer, one satisfactory reference from a prior job experience and one personal reference both with no evidence of abuse, neglect, or exploitation of an incapacitated or older adult is acceptable; and

(3) Submit to a search of the VDSS CPS Central Registry if the individual receiving services is a minor child. The provider shall not hire any persons who have been convicted of barrier crimes as identified in § 32.1-162.9:1 the Code of Virginia or has a founded complaint confirmed by the VDSS CPS Central Registry.

3. The RN or LPN must have (i) a documented provider training program or (ii) at least six months of related clinical nursing experience meeting the needs of the individual to receive care. Regardless of whether a nurse has six months of experience or completes a provider training course, the provider agency shall be responsible for assuring all nurses who are assigned to an individual are competent in the care needs of that individual.

4. Nursing services must be provided under the supervision of a licensed, registered nurse (RN supervisor) in the Commonwealth.

a. RN supervisors shall meet the following requirements:

(1) Be verified as currently licensed to practice nursing in the Commonwealth;

(2) Have at least one year of verified related clinical nursing experience as an RN;

(3) Clinical experience may include work in an acute care hospital, public health clinic, home health agency, rehabilitation hospital, or nursing facility; and

(4) Have a satisfactory work history as evidenced by two satisfactory reference checks from prior job experience, including no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children, recorded in the nurse's personnel file. If the RN has worked for a single employer, one satisfactory reference from a prior job experience and one personal reference both with no evidence of abuse, neglect, or exploitation of an incapacitated or older adults or children is acceptable, and the RN supervisor shall submit to a criminal record check obtained through the Virginia State Police. If the individual receiving services is a minor, the RN supervisor must also submit to a search of the VDSS CPS Central Registry. The provider shall not hire any RN supervisor with findings of barrier crimes identified in § 32.1-162.9:1 of the Code of Virginia or founded complaints in the VDSS CPS Central Registry.

b. As part of direct supervision, the RN supervisor shall make, at a minimum, a visit every 30 days to ensure both quality and appropriateness of nursing services to assess the individual's and the individual's representative's satisfaction with the services being provided, to review the plan of care and to update and verify the most current physician signed orders are in the home. When a delay occurs in the RN supervisor's visits because the individual is unavailable, the reason for the delay shall be documented in the individual's record, and the visit shall occur as soon as the individual is available. Failure to meet this standard may result in a DMAS recovery of payments made. Additional supervisory visits may be required under the following circumstances:

(i) at the provider's discretion;

(ii) at the request of the individual when a change in the individual's condition has occurred;

(iii) any time the health, safety, or welfare of the individual could be at risk; and

(iv) at the request of the DMAS staff. The RN is responsible for documentation of the visit's date, time, and evaluation.

c. The RN supervisor shall:

(1) Use and foster a person centered planning team approach to nursing services;

(2) Ensure choice of services is made by the individual, legally authorized guardian, or responsible party if a minor;

(3) Ensure personal goals of the individual are respected;

(4) Conduct the initial evaluation visit to initiate EPSDT private duty nursing services in the primary residence;

(5) Regularly evaluate the individual's status and nursing needs and notify the primary care provider if the individual no longer meets criteria for private duty nursing;

(6) Complete the Plan of Care and update as necessary for revisions;

(7) Ensure provision of those services requiring substantial and specialized nursing skill and that assigned nurses have the necessary licensure;

(8) Initiate appropriate preventive and rehabilitative nursing procedures;

(9) Perform an assessment, at least every 30 days (the monthly nursing assessment cannot be made by the nurse providing care in the home); RN Monthly Supervisory Visits shall be completed in the primary residence at least every other visit. Visits may be conducted at school every other visit if necessary;

(10) Coordinate private duty nursing services;

(11) Inform the physician and case manager as appropriate of changes in the individual's condition and needs;

(12) Educate the individual and family or caregiver in meeting nursing and related goals;

(13) Supervise and educate other personnel involved in the individual's care;

(14) Ensure that required documentation is in the individual's agency record;

(15) Ensure that all employees are aware of the requirements to report suspected abuse, neglect, or exploitation immediately to Adult Protective Services or Child Protective Services, as appropriate. A civil penalty may be imposed on mandated reporters who do not report suspected abuse, neglect, or exploitation to VDSS as required;

(16) Ensure services are provided in a manner that is in the best interest of the individual and does not endanger the individual's health, safety, or welfare;

(17) Recommend staff changes when needed;

(18) Report to DMAS or the DMAS contractor any unethical or incompetent practices that jeopardize public safety or cause a risk of harm to individuals, including household issues that may jeopardize the safety of the private duty nurse; and

(19) Ensure that all nurses and caregivers are aware that timesheets must be accurate with arrival and departure time of the nurse and that falsifying timesheets is Medicaid fraud.

d. Parents (natural, step-parent, adoptive, foster parent, or other legal guardian), spouses, siblings, grandparents, grandchildren, adult children, or any person living under the same roof with the individual shall not provide private duty nursing services for the purpose of Medicaid reimbursement for the individual.

E. Service limits. Private duty nursing services are limited to the hours of skilled nursing care and medically-necessary supervision as specified in the Plan of Care signed by the child's physician (per §§ 54.1-2957 and 54.1-2957.02 of the Code of Virginia, signature by a nurse practitioner is acceptable in certain circumstances) and limited to the number of hours approved by DMAS or the DMAS contractor through the DMAS service authorization form (DMAS-62). Authorization of the number of medically necessary hours is based on assessing an individual's medical and support needs related to respiratory function, cardiovascular access and medications, wound care, feeding, central nervous system function, assessments that require the skills of a medical professional, toileting, and any other additional medical or support needs that require the skills of a licensed clinician. These medical and support needs are encompassed in the DMAS-62, and the number of hours approved will be based on medical needs final score, as detailed in the DMAS-62. Individuals younger than 21 years of age qualifying under EPSDT shall receive the services described in excess of any State Plan limit, up to 24 hours per day, if services are determined to be medically necessary to correct, ameliorate or maintain the member's health condition and are prior authorized by the DMAS or the DMAS contractor.

12 Va. Admin. Code § 30-50-132

Derived from Virginia Register Volume 40, Issue 5, eff. 10/6/2023, exp. 4/5/2025 (Emergency).

Statutory Authority: § 32.1-325 of the Code of Virginia, 42 USC § 1396 et seq.