Private Duty Nursing

1
Private Duty Nursing

• Program Training
• for
• Medicaid Private Duty Nursing Providers
• Prepared by the Home Care Initiatives Unit
• Home and Community Care Section
• N. C. Division of Medical Assistance

2
Private Duty Nursing Definitions

• Private Duty Nursing (PDN) is a Medicaid program
  providing substantial, complex, and continuous
  skilled nursing services (see slides 3-6) to
  beneficiaries at home.
• PDN services are provided
• only in a beneficiarys private primary
  residence,
• under the direction of a physician-signed
  individualized plan of care,
• by a RN or LPN licensed with the NCBON and
  employed by a licensed home care agency.

3
Definitions

• Skilled Nursing
• Skilled nursing is defined by 10A NCAC 13J.1102.
  

4
Definitions

• Skilled Nursing (continued)
• Skilled nursing does not include tasks that can
  be delegated to unlicensed personnel pursuant to
  2l NCAC 36.0401

5
Definitions

• Substantial
• Requires the assessment and judgment of a
  licensed nurse.

6
Definitions

• Complex
• Complex means that there are scheduled, hands-on
  nursing interventions. Observation in case
  something happens is not covered.

7
Definitions

• Continuous
• Continuous means there are nursing assessments
  requiring interventions at least every 3-4 hours
  during the period Medicaid covered PDN services
  are provided.

8
Definitions

• Significant Change in Condition
• Significant change is defined as a change in the
  beneficiarys care needs that impacts more than
  one area of functional health status and requires
  more multidisciplinary review or a revision of
  the plan of care.

9
General Provisions

• A beneficiary must have NC Medicaid on the date
  of service.
• PDN is not covered for NC Health Choice
  beneficiaries.

10
EPSDT

• There are exceptions to policy limitations for
  beneficiariess under 21

11
EPSDT

• Exceptions to EPSDT
• unsafe, ineffective, or experimental/investigation
  al.
• not medical in nature or not generally recognized
  as an accepted method of medical practice or
  treatment.
• Not medically necessary to correct or ameliorate
  a defect, physical or mental illness, or a
  condition health problem

12
EPSDT and Prior Approval Requirements

• If the service, product, or procedure requires
  prior approval, the fact that the recipient is
  under 21 years of age does NOT eliminate the
  requirement for prior approval.
• IMPORTANT ADDITIONAL INFORMATION about EPSDT and
  prior approval is found in the Basic Medicaid and
  NC Health Choice Billing Guide, sections 2 and 6,
  and on the EPSDT provider page. The Web addresses
  are specified below.
• Basic Medicaid and NC Health Choice Billing
  Guide http//www.ncdhhs.gov/dma/basicmed/
• EPSDT provider page http//www.ncdhhs.gov/dma/eps
  dt/

13
When the Procedure,Product,or Service Is Covered

• General Eligibility Criteria
• Procedures,products,and services are covered when
  medically necessary and
• the plan is individualized and consistent with
  symptoms and diagnosis,and not in excess of the
  beneficiarys needs.
• can be furnished safely and no equally effective
  and less costly treatment is available.
• are not be for the convenience of the
  beneficiary,family,or provider.

14
Specific Eligibility Criteria

• The beneficiary may have limitations on coverage
  based on their eligibility category
• Fee-for-Service Medicaid Categories
• Beneficiaries covered by regular Medicaid are
  eligible to apply for PDN services.
• Medicaid for Pregnant Women (MPW)
• Pregnant women are eligible to apply for PDN
  services if the services are medically necessary
  for a pregnancy-related condition.
• Medicare Qualified Beneficiaries (MQB)
• Medicaid recipients who are Medicare-qualified
  beneficiaries (MQB) are not eligible for Private
  Duty Nursing.
• Managed Care
• Medicaid recipients participating in a managed
  care program, including Medicaid health
  maintenance organizations and Community Care of
  North Carolina programs (Carolina ACCESS and
  ACCESS II/III), must access home services,
  including PDN, through their primary care
  physician.

15
Specific Eligibility Criteria

• Physician Order
• PDN services must be requested by and ordered by
  the beneficiarys attending physician using the
  CMS-485
• (MD or DO licensed by the North Carolina Board
  of Medicine and enrolled with Medicaid) on the
  CMS-485

16
Specific Eligibility Criteria

• Prior approval by DMA

17
Specific Eligibility Criteria

• Location of Service
• PDN is provided in the private residence of the
  beneficiary. The basis for PDN approval is based
  on the need for skilled nursing care in the home.
  A beneficiary who is authorized to receive PDN
  services in the home may make use of the approved
  hours outside of that setting when normal life
  activities temporarily take him or her outside
  that setting. Normal life activities include
  supported or sheltered work settings, licensed
  child care, school and school related activities,
  and religious services and activities. Normal
  life activities do not include inpatient
  facilities, outpatient facilities, hospitals,
  physicians offices, or other medical settings.

18
Specific Eligibility Criteria

• Caregiver Support
• The beneficiary has at least one trained primary
  informal caregiver to provide direct care to the
  beneficiary during the planned and unplanned
  absences of PDN staff.
• It is recommended that there be a second trained
  informal caregiver for instances when the primary
  informal caregiver is unavailable due to illness,
  emergency, or need for respite.

19
Health Eligibility Criteria

• Standard PDN Services
• To be eligible for standard PDN services, the
  beneficiary shall
• be dependent on a ventilator for at least eight
  hours per day, or
• meet at least four of the following criteria
• unable to wean from a tracheostomy.
• require nebulizer treatments at least two
  scheduled times per day and one as needed time
  per day.
• require pulse oximetry readings every nursing
  shift.
• require skilled nursing or respiratory
  assessments every shift due to a respiratory
  insufficiency.
• need (PRN) oxygen or has PRN rate adjustments at
  least two times per week.
• require tracheal care at least daily.
• require PRN tracheal suctioning. Suctioning is
  defined as tracheal suctioning requiring a
  suction machine and a flexible catheter.
• at risk for requiring ventilator support.

20
Expanded PDN Services

• Beneficiaries who meet all of the criteria for
  standard nursing services plus at least one of
  the criteria below may be eligible for expanded
  PDN services
• use of respiratory pacer.
• dementia or other cognitive deficits in an
  otherwise alert or ambulatory recipient.
• Infusions, such as through an intravenous, PICC,
  or central line.
• seizure activity requiring use of PRN use of
  Diastat, oxygen, or other interventions that
  require assessment and intervention by a licensed
  nurse.
• primary caregiver who is 80 or more years of age
  or who had disability confirmed by the Social
  Security Administration and disability interferes
  with care-giving ability.
• determination by Child Protective Services or
  Adult Protective Services that additional hours
  of PDN would help ensure the recipients health,
  safety, and welfare.
• Expanded PDN services in most cases allows an
  additional 14 hours per week - as long as that
  new total does not exceed the program maximum
  limit of 112 hours per week.

21
Significant Change In Condition

• Beneficiaries who meet one of the following
  criteria may be eligible for a short-term
  increase in service. The amount and duration of
  the increase is based on medical necessity and
  approved by the PDN Nurse Consultant. No
  short-term-increase may last more than four
  calendar weeks.
• beneficiary with new tracheostomy, ventilator, or
  other technology need, immediately post
  discharge, to accommodate the transition and the
  need for training of informal caregivers.
  Services will generally start at a high number of
  hours and be weaned down to within normal policy
  limits over the course of the four weeks. For ex
  24 hrs x 1wk, 20hrs.x1 wk
• an acute, temporary change in condition causing
  increased amount and frequency of nursing
  interventions.
• a family emergency, when the back-up caregiver is
  in place but requires additional support because
  of less availability or need for reinforcement of
  training.

22
When PDN Is Not Covered

• Procedures, products, and services related to
  this policy are not covered when
• the beneficiary does not meet the Medicaid
  category, general, specific, or health
  eligibility requirements
• the beneficiary does not meet the medical
  necessity criteria the procedure, product, or
  service unnecessarily duplicates another
  providers procedure, product, or service or
• the procedure, product, or service is
  experimental, investigational, or part of a
  clinical trial.

23
Specific Non-Covered Criteria

• PDN is not covered if any of the following are
  true
• the beneficiary is receiving medical care in a
  hospital, nursing facility, or other setting
  where licensed personnel are employed
• the beneficiary is a resident of an adult care
  home, group home, family care home, or nursing
  facility
• the service is for custodial, companion, or
  respite services (short-term relief for the
  caregiver) or medical or community transportation
  services
• the nursing care rendered can be delegated to
  unlicensed personnel (Nurse Aide I or Nurse Aide
  II), in accordance with 21 NCAC 36.0401 and 21
  NCAC 36.0221(b)
• the purpose of having a licensed nurse with the
  beneficiary is for observation or monitoring in
  case an intervention is required

24
Continued Non-Coverage Criteria

• the service is for the beneficiary or caregiver
  to go on vacation or overnight trips away from
  the beneficiarys private primary residence.
• Note Short-term absences from the home that
  allow the beneficiary to receive care in an
  alternate setting for a short period of time may
  be allowed as approved by the PDN Nurse
  Consultant and when not provided for respite,
  when not provided in an institutional setting,
  and when provided according to nurse and home
  care licensure regulations
• services are provided exclusively in the school
  or home school
• the beneficiary does not have informal caregiver
  support available
• the service duplicates services provided by
• home health nursing services
• respiratory therapy treatment (except as allowed
  under Policy 10D Independent Practitioners
  Respiratory Therapy Services)
• The Home Infusion Therapy (HIT) program,
• The Community Alternatives Program for Children
  (CAP/C)
• the beneficiary is receiving Hospice Services,
  except as those services may apply to children
  under the Affordable Care Act.

25
Requirements and Limitations on Coverage

• Prior approval is required for Medicaid
  beneficiaries.
• Documents required for prior approval
• the PDN Prior Approval referral form
• a physicians request. The physicians request
  consists of either
• Physicians Request Form for PDN Services
• letter of medical necessity.
• all health care records and any other records
  that support the beneficiary has met the program
  criteria
• if the Medicaid beneficiary is under 21 years of
  age, information supporting that all EPSDT
  criteria are met and evidence-based literature
  supporting the request, if available.
• Verification of caregiver employment schedule.
• Verification consists of a statement on employer
  letterhead signed by a supervisor or
  representative from the employers Human
  Resources Department, detailing the employees
  current status of employment (such as active or
  on family medical leave) and typical work
  schedule. If a caregiver is self employed or
  unable to obtain a letter, the Verification of
  Employment form may be used.
• Home Health Certification and Plan of Care form
  (CMS-485)

26
Physician Request Should Include

• The current diagnosis(es)
• History of the illness, injury, or medical
  condition requiring PDN services
• Date of onset and date(s) of any related
  surgeries
• The projected date of hospital discharge, if
  applicable
• A prognosis that identifies the specific
  expectations for the beneficiarys recovery from
  the illness, injury, or medical condition
  requiring the PDN hours
• The specific licensed nursing interventions
  requested, the frequency of those interventions,
  and the estimated length of time PDN will be
  required and
• The family members and other caregivers available
  to furnish care and the training they have been
  or will be provided.

27
A complete request for initial prior approval
contains the following information

• beneficiarys name, address, date of birth and
  Medicaid Identification Number MID
• the specific number of hours per day requested
• the name, address, and phone number, and provider
  number of the PDN provider chosen by the
  beneficiary
• requested start of care date for PDN
• diagnosis and skilled interventions required
• if applicable, recent hospital admission and
  discharge summaries
• third party insurance coverage
• caregiver availability and teaching required and
• the name of the beneficiarys attending physician
  who will be signing the plan of care.

28
Prior Approval Continued

• Documentation that is submitted without this
  information will be treated as unable to process
  or as an incomplete request per Medicaid due
  process procedures.
• Note Per the current due process procedures, an
  initial request is defined as a request that the
  beneficiary was not authorized to receive on the
  day immediately preceding the date of the receipt
  of the request.
• If DMA or its designee approves the initial
  request for PDN services, DMA will send the PDN
  service provider a notification letter within 15
  business days of the receipt of all required
  information. Required information includes
  notification of the start of care date and the
  unsigned orders from the agency. A copy of the
  letter will be sent to the beneficiarys
  attending physician, the beneficiary, or the
  beneficiarys representative. The approval letter
  includes
• the beneficiarys name and MID number
• the name and provider number of the authorized
  PDN service provider
• the number of hours per week approved for PDN
  services, beginning with Sunday at 1201 am and
• the starting and ending dates of the approved
  period, usually 30 to 60 calendar days, depending
  on the beneficiarys medical condition.

29
Prior Approval of Reauthorization

• The following documents are required for
  reauthorizations
• The clinical medical record as per Subsection 7.2
  and in accordance with 10A NCAC 13J.1401 and 10A
  NCAC 13J.1402
• A copy of the completed PDN Medical
  Update/Beneficiary Information Form, which also
  indicates the date of the last physician visit
• or
• A copy of the Medical Update and Patient
  Information Form (CMS-486)
• A copy of the Home Health Certification and Plan
  of Care Form (CMS-485) signed and dated by the
  attending physician and indicating specific
  recertification dates, frequency, and duration of
  PDN services being requested.
• A verbal order is acceptable in order to have
  the CMS-485 submitted within ten calendar days
  prior to the recertification date and receive a
  verbal authorization for services however, the
  physician-signed form must be submitted to DMA
  before final written approval is granted

30
Reauthorizations Continued

• The completed HNRC
• At DMAs discretion, an in-home assessment may be
  performed by DMA or its designee
• Verification of caregivers employment schedule
  annually and with any changes. Verification
  consists of a statement on employer letterhead
  signed by a supervisor or representative from the
  employers Human Resources Department, detailing
  the employees current status of employment (such
  as active or on family medical leave) and typical
  work schedule. If a caregiver is self employed or
  unable to obtain a letter, the Verification of
  Employment form may be used and
• Nurses notes from the latest certification period
  as requested by Consultant.

31
Reauthorizations Continued

• Documentation that is submitted without this
  information will be treated as unable to process
  or as an incomplete request per Medicaid due
  process procedures.
• To receive approval for continuation of PDN
  services beyond the approved period, the PDN
  service provider shall submit the reassessment
  information to DMA at least 10 calendar days
  PRIOR to the end date of the recertification
  period (current approved period). Authorization
  will be finalized upon receipt of all requested
  information, including signed physician order.
• Note If the request is received by DMAs Home
  Care Initiatives HCI Unit MORE than one day after
  the end of the current authorization period, the
  request will be treated as an Initial Request

32
Approved Reauthorizations

• DMA will
• forward a written notification to the PDN service
  provider in accordance with the current
  beneficiary notices procedure
• forward a copy of the authorization for services
  to the beneficiary (and the beneficiarys
  representative, if applicable) and
• once the signed physician order is received,
  enter the required information into the Medicaid
  fiscal agents claims system to allow payment of
  claims submitted for the approved services.
• Payment of claims for approved services will not
  be generated until the physician signed CMS 485
  is submitted to DMA for the current certification
  period. Please note the amount of time billed
  must match the amount of time provided and
  documented .

33
Limitation or Requirements

• Re-evaluation during the Approved Period
• If the beneficiary experiences a significant
  change of condition, the PDN service provider
  shall notify DMA or its designee of the need
  either to change the number of PDN hours required
  to meet the beneficiarys needs or to terminate
  PDN, based on physicians orders. Services will
  be re-evaluated at that time. Please note that
  the PDN consultant may require documentation such
  as discharge summaries or physician progress
  notes to substantiate the need for an increase or
  decrease in services.

34
Verbal Orders

• If the physician requests that PDN services begin
  before the service provider receives written
  orders, the PDN service provider may act on the
  physicians verbal orders subject to DMA
  approval. A licensed nurse or other appropriate
  home care professional shall record the verbal
  orders on the Home Health Certification and Plan
  of Care Form (CMS-485) and in accordance with 10A
  NCAC 13J, The Licensing of Home Care Agencies.
  The verbal order must be submitted to DMA HCI
  office, with 10 days prior to recertification end
  date. The verbal order shall include
  recertification dates, frequency and duration of
  request PDN hours.

35
Plan of Care

• The plan of care must have
• All pertinent diagnoses, including the
  beneficiarys mental status
• The type of services, medical supplies, and
  equipment ordered
• Weekly limit of hours or daily limit.
• Specific assessments and interventions to be
  administered by the nurse
• individualized nursing goals with measurable
  outcomes
• Verbal order, date, signed by RN if CMS-485
  (Locator 23) is not signed by the physician in
  advance of the recertification period
• The beneficiarys prognosis, rehabilitation
  potential, functional limitations, permitted
  activities, nutritional requirements,
  medications-indicating new or changed in last 30
  calendar days, and treatments
• Teaching and training of caregivers
• Safety measures to protect against injury
• Disaster plan.
• Discharge plans individualized to the
  beneficiary and
• The POC recertification period is a maximum of 60
  days unless otherwise authorized by DMA.
• Note Refer to Attachment B for an example of the
  Home Health Certification and Plan of Care Form
  (CMS-485).

36
Retroactive Coverage

• Retroactive coverage for Initial Requests
• PDN services may be requested for up to five
  business days prior to the initial request of PDN
  coverage. If the request is not received within
  five business days, services are not eligible for
  reimbursement. This only applies to initial
  requests not ongoing recertification's where
  coverage has lapsed due to failure to submit in
  accordance with due process procedures.

37
PDN in Schools

• Individuals and caregivers are responsible for
  determining if the beneficiary is receiving the
  appropriate nursing benefit in the school system
  and formulating the childs Individualized
  Education Plan (IEP) to include nursing coverage
  in the school system. If any nursing hours are
  approved for school coverage, these hours are
  included in the total hours approved by DMA.
• The nurse shall document the hours and specific
  place of service when care is rendered in a
  school, included how transported to school (bus,
  parent vehicle, etc). All other PDN requirements
  must be met for example, there must be a CMS-485
  in addition to the IEP and it must be signed only
  be a Medical Doctor (MD) or Doctor of Osteopathic
  Medicine (DO).

38
Determining the Amount, Duration, Scope, and
Sufficiency of Services

• DMA or its designee determines the amount,
  duration, scope, and sufficiency of PDN services
  required after reviewing the recommendations of
  the beneficiarys attending physician and the
  following characteristics of the beneficiary
• Primary and secondary diagnoses.
• Overall health status.
• Level of technology dependence.
• Current and updated individualized plan of care
• Need for specific medical care and services
  provided under the Medicaid PDN services benefit.
• Clinical health care record
• Amount of family assistance available.
  Verification of employment hours will be
  conducted annually. Allowances will not be made
  for second jobs, overtime, or combination of work
  and school, when the additional hours will cause
  the policy limit to be exceeded.
• PDN services are authorized in the amounts that
  are medically necessary based on the medical
  condition of the beneficiary and the amount of
  caregiver assistance available.

39
Approved hours determined
Caregiver availability Standard Expanded
2 caregivers 56 hrs 70hrs
1 caregiver with or without any other CGs 76 hrs. 90 hrs.
2 or more partial CGs 56 plus work time max 96 hrs. 70hrs plus work time max 110hrs.
1 partial CG 70 hrs plus work time up tp 112hrs. Per week 90 hrs per week plus work time for max up to 112hrs per week
40
Definitions

• Fully available caregiver is on who lives with
  beneficiary ,not employed, and is physically and
  cognitively able to provide care.
• Partially available caregiver is one who lives
  with the beneficiary and has verified employment,
  or who is disabled as determined by the SSA and
  that disability interferes with the ability to
  provide care.

41
Other considerations in determining hours

• Approved hours for other formal support programs
  such CAPIDD apply towards the maximum of 112hrs.
• Hours approved are on a per week basis beginning
  12.01am Sunday and ending 1200am Saturday.
• Maximum for any beneficiary is 112.
• Unused hours can not be banked.
• Individuals who were receiving greater than max
  when the policy took effect (12/1/2012) may
  continue receiving that amount of services until
  nursing interventions decrease, there change in
  caregiver status, or the beneficiary hospitalized
  greater than 30 days.
• Individuals who, when the policy took effect
  (12/1/2012), were receiving less than 112 hrs but
  exceeding the parameters have until 12/1/2013 to
  decrease their hours to within the parameters.

42
Request for changes

• Any request for change in amount,scope,frequency
  ,or duration must be ordered by physician and
  approved by PDN consultants
• Plan of Care Changes any increase or decrease in
  amount,scope,duration must be approved by the
  consultants. Must have physician order faxed to
  DMA.
• Temporary changes To decrease services for a
  holiday or vacations less than seven days do not
  require DMA approval. Agency to document missed
  shifts and notify MD.
• Emergency changes-Emergency changes after hours
  that are based on a true emergency must be
  reported to DMA next business day and must get
  supplemental order from MD. Note Follow-up
  reports will be requested.

43
Termination/Reduction

• The PDN service provider ,the physician, or DMA
  may terminate or reduce PDN services. Upon
  termination or reduction DMA enters the
  information into the fiscal agent claims system.

44
Notification of Termination

• Notify DMA within 5 business days of discharge
  and send a copy of the MD order to stop servcies.
  DMA will send a letter to the agency
  acknowledging receipt.
• PDN services can be terminated for the following
  another payer source has been identified, the
  beneficiary is no longer Medicaid eligible, or
  the beneficiary is hospitalized longer than 30
  days.
• If DMA initiates the termination because it has
  determined that the beneficiary no longer meets
  eligibility based on review, Medicaid due process
  procedures will be followed.
• Note If the beneficiarys physician or service
  provider initiates the discharge, that decision
  cannot be appealed to DMA. Only DMA decisions
  may be appealed to DMA.

45
Notification of Reduction

• Notify DMA within five business days of reduction
  and fax MD order. DMA will send letter to the
  provider acknowledging receipt.
• If DMA initiates the reduction additional
  information may be requested from the service
  provide for medical review. If the information is
  not provided in 10 business the provider will be
  notified in writing of the reduction of PDN
  services and due process procedures will be
  followed.

46
Changing Service Providers

• Transfer of Care Two Branch offices of the Same
  Agency
• The new PDN provider shall facilitate the change
  by being responsible for the following
• Submitting information to DMA within 5 business
  days of the request
• Coordinating the date of transfer
• Obtaining a signed 485
• Obtaining written permission from the beneficiary
  or legal guardian for the transfer.
• Ensuring that written and verbal orders are
  verified and documented according to 10A
  NCAC13J,Licensing of Home Care Agencies.
• Forwarding to DMA prior to transfer written
  notification.

47
Transfer Between 2 Different Agencies

• Submit to DMA the following
• The prior approval form
• The letter of medical necessity
• Any other requested documents by DMA
  consultant

48
Discharge Summary

• The PDN service provider shall forward to DMA a
  discharge summary that specifies the last day PDN
  services were provided.

49
Approval process

• After all requirements are met, DMA approves the
  new PDN provider and forwards an approval letter
  to the provider and the beneficiary or the
  beneficiarys representative.

50
Limitations on the Amount ,Frequency, and Duration

• Unused service hours cannot bank
• Unauthorized Hours-excess hours not approved by
  DMA are providers financial responsibility.
• Transportation-PDN nurse cannot drive the
  beneficiary.
• Medical settings Not covered in a setting where
  licensed personnel are employed.

51
Weaning of a Medical Device

• The DMA Nurse Consultant may authorize
  continuation of PDN services for a brief period
  after the beneficiary no longer requires a
  medical device that qualified him/her for the
  program. Normally this period will not exceed
  two weeks.

52
Coordination of Care

• The attending physician and the PDN provider
  agency are responsible for monitoring the
  beneficiarys care and initiating appropriate
  changes in PDN services.
• Transfer between Health Care Settings-If a
  beneficiary is placed in a different health care
  setting the PDN provider shall contact DMA prior
  to discharge to discuss any changes in services.
  An HP and /or discharge summary shall be
  submitted.
• Drug Infusion Therapy-The Durable Medical
  Equipment supplier provides the equipment, drugs,
  and supplies under Medicare Part D or Medicaid
  coverage. The PDN Provider is responsible for
  the administration and caregiver teaching.
• Enteral/Parental Nutrition-DME supplier provides
  the equipment and supplies . Home Health nursing
  would be a duplication.

53
Coordination of Care

• 4.Home Health Nursing May not be provided
  concurrently with PDN services.
• 5.Medical Supplies-Supplies are covered as
  defined in Clinical Coverage Policy3A Home Health
  Services.

54
Providers Eligible to Bill

• To be eligible to bill for services, products,
  and procedures the PDN provider shall meet the
  following
• Meet Medicaid qualifications
• Be currently Medicaid enrolled
• Bill only for services that are within scope of
  practice.
• Nursing documentation must substantiate and match
  services billed. Can not bill for more
  units/hours than authorized.

55
Agency type

• PDN agencies are licensed by the North Carolina
  Division of Health Service Regulation. Each
  office providing services shall have an
  individual PDN provider number.

56
Agency Responsibilities

• Ensure qualified and competent staff
• Be accredited by June 1, 2014 by JCAHO,ACHC,or
  CHAP.
• Ensure staff have appropriate training and
  experience.
• Verify education, license, and training prior to
  hire
• Ensure the nurse assigned has the skills to meet
  the POC
• Ensure staff have continuing education hours
• Develop orientation plan for policies and
  procedures.

57
Provider Relationship to Beneficiary

• In order for PDN services to be reimbursed the
  agency may not employ
• Member of the beneficiarys family
• One who maintains his or her residence with the
  beneficiary
• Nurse who lives with the beneficiary

58
Nurse supervisor

• The PDN supervisor shall have at least 2 years
  experience of home care with medically fragile
  beneficiaries.

59
Additional Requirements

• Compliance- Must comply with all
  federal,state,HIPPA,local laws, and record
  retention requirements.
• Documentation-The PDN agency must document
  complete accurate records of all care,
  beneficiary condition, nursing interventions,
  treatment and include the following
• date, time of skilled care
• Interventions including beneficiary response
• Signature of legal representative acknowledging
  time spent and services
• Hourly Nursing Review form
• Supplies used
• Who is taking report or giving report
• Caregiver availability , training , and
  competency
• Safety issues and interventions
• Coordination with other home care services such
  PT,OT,ST.
• Supervisory visits

60
Verification of Eligibility

• PDN provider is responsible for verifying
  eligibility, other insurance coverage, and living
  arrangements before initiating services.

61
Family and Other Caregivers

• Caregivers-Shall have one trained primary
  caregiver and it is recommended to have a second
  caregiver in case of emergencies.
• Training-PDN provider will document the training
  needs of the caregiver. Training by the PDN
  provider and the hospital should be documented.
• Competency-Family will demonstrate competence,
  skills, and ability to carry out the plan of
  care.
• Emergency Plan-Emergency plan shall be part of
  the POC and caregivers aware if the beneficiary
  requires emergency care.
• Evaluation of Health Safety-PDN provider is
  responsible for the health, safety, and welfare
  of the beneficiary. Notify DMA of DSS
  involvement.

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Patient Self Determination Act

• The Patient Self Determination Act of 1990,
  Sections 4206 and 4751 of the Omnibus Budget
  Reconciliation Act of 1990, P.L.101-508 requires
  that Medicaid-certified hospitals and other
  health care providers and organizations, give
  patients information about their right to make
  their own health decisions, including the right
  to accept or refuse medical treatment. Providers
  shall comply with these guidelines. Basic
  Medicaid and NC Health Choice Billing Guide
  http//www.ncdhhs.gov/dma/basicmed/

63
Marketing Prohibition

• Agencies providing PDN under the Medicaid program
  are prohibited for offering gifts or services for
  the purpose of inducing or enticing beneficiaries
  to choose them as their PDN provider.

64
How to Complete the POC(485)

• Completion of Form CMS-485, Home Health
  Certification and Plan of Care.--Form CMS-485
  meets the regulatory requirements (State and
  Federal) for both the physician's home health
  plan of care and home health certification and
  recertification requirements.
• Complete the following
• Patient's Medicaid
• 2. Start of Care Date.--Enter the 6 digit month,
  day, year on which covered home health services
  began ,i.e., MMDDYY (e.g., 101593). The start of
  care (SOC) date is the first Medicaid billable
  visit. This date remains the same on subsequent
  plans of treatment until the patient is
  discharged.
• 3. Certification Period.--Enter the 2 digit
  month, day, year, MMDDYY (e.g., 101593- 121593),
  which identifies the period covered by the
  physician's plan of care. The "From" date for the
  initial certification must match the start of
  care date. The "To" date can be but never exceed,
  two calendar months and mathematically never
  exceed 62 days.

65
485 continued

• 4 . Medical Record No -This is the patient's
  medical record number that is assigned by the HHA
  and is an optional item. If not applicable, the
  agency enters "N/A."
• 5. Provider No. -This is the -digit number
  issued by Medicaid to the HHA. It always starts
  with 7100___.
• 6 .Patient's Name and Address - The HHA enters
  the patient's last name, first name, and middle
  initial as shown on the health insurance card and
  the street address, city, State, and ZIP code.
• .7 Provider's Name Address and Telephone No. -The
  HHA enters its name and/or branch office (if
  appropriate), street address (or other legal
  address), city, State and ZIP code and telephone
  number.
• 8.Date of Birth The patient's date of birth
  (month, day, year) in numbers, i.e.,MMDDYYYY
  (04031920) is entered.
• 9. Sex The patient's sex is checked in the
  appropriate box.

.
66
485 continued

• 10 .Medications Dose, Frequency, Route. The
  physician's orders for all medications including
  the dosage, frequency and route of administration
  for each drug must be listed. Drugs, which cannot
  be listed on the plan of care due to lack of
  space, are listed on an addendum.
• 11. Principal Diagnosis,ICD-9-CM Code and Date of
  Onset, Exacerbation.
• The principal diagnosis is the diagnosis most
  related to the current POC. The diagnosis may or
  may not be related to the patient's most recent
  hospital stay, but must relate to the services
  rendered by the HHA. If more than one diagnosis
  is treated concurrently, the diagnosis that
  represents the most acute condition and requires
  the most intensive services should be entered.

67
485 Continued

• 12. Surgical Procedure, Date, ICD-9-CM Code. The
  surgical procedure relevant to the care being
  rendered is entered.
• 13. Other Pertinent Diagnoses Dates of
  Onset/Exacerbation ICD-9-CM Codes. Enter all
  pertinent diagnoses relevant to the care
  rendered.
• 14. DME and Supplies- All non-routine supplies
  must be specifically ordered by the physician or
  the physician's order for services must require
  use of the specific supplies. See PDN policy
  5.3.3 Plan of Care.
• 15. Safety Measures -The physician's instructions
  for safety measures are listed.

68
485 Continued

• 16. Nutritional Requirements-The HHA enters the
  physician's orders for the diet. This includes
  specific therapeutic diets and/or any specific
  dietary requirements. Fluid needs or restrictions
  are recorded. Total parenteral nutrition (TPN)
  can be listed under this item or under
  medications if more space is needed.
• 17. Allergies-Medications to which the patient
  is allergic and any food or products such as
  adhesive tape,etc.
• 18A. Functional Limitations-All items that
  describe the patient's current limitations
  assessed by the physician and the agency are
  indicated.
• 18B. Activities Permitted -The activity(ies) that
  the physician allows and/or for which physician
  orders are present are indicated.
• 19. Mental Status- The block(s) most appropriate
  to describe the patient's mental status is
  checked.

69
485 Continued

• 20. Prognosis -A check is placed in the box,
  which specifies the most appropriate prognosis
  for the patient.
• 21. Orders for Discipline and Treatments (Specify
  Amount, Frequency, Duration). Orders must include
  all disciplines and treatments, even if they are
  not billable to Medicaid.Please include any other
  services the recipient is receiving such as
  CAPMR/IDD,PT,OT,Speech, and PCS services. POC
  must be specific include size of tracheostomy,how
  often changed and by whom, vent settings, hours
  on the vent, sizes of suction and Foley
  catheters,etc, For example 12 hours of PDN x 7
  days. Maintain patency of 3.5Ped Bivona.Trach
  change by SN/PCG q week and prn respiratory
  distress.
• 22. Goals/Rehabilitation Potential/Discharge-This
  reflects the physician's description of the
  achievable goals and the patient's ability to
  meet them as well as plans for care after
  discharge.

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485 Continued

• 22.Rehabilitation potential -addresses the
  patient's ability to attain the goals and an
  estimate of the time needed to achieve them.
• 23 Nurse's Signature and Date of Verbal Start of
  Care. This verifies for surveyors, CMS'
  representatives, including Medicaid that a
  registered nurse or qualified therapist
  responsible for furnishing or supervising the
  patient's care spoke to the attending physician
  and received verbal authorization to visit the
  patient. Each reauthorization requires an updated
  verbal start of care every 60 days.
• Physician's Name and Address. The agency prints
  the physician's name and address. The attending
  physician is the physician who established the
  plan of treatment and who certifies and
  re-certifies the medical necessity of the home
  health visits and/or services. Supplemental
  physicians involved in a patient's care are
  mentioned on the addendum only. The physician
  must be qualified to sign the certification and
  plan of care in accordance with 42 CFR 424
  Subpart B.

71
485 Continued

• 25.The date the agency received the signed POC
  from the attending/referring physician is
  entered. It is required only if the physician
  does not date Item 27.
• 26. Physician Certification-This statement serves
  to verify that the physician has reviewed the POC
  and certifies the need for the services.
• 27. Attending Physician's Signature and Date- The
  attending physician signs and dates the plan of
  care prior to the claim being submitted for
  payment rubber signature stamps are not
  acceptable. The form may be signed by another
  physician who is authorized by the attending
  physician to care for his/her patients in his/her
  absence.
• 28 .Penalty Statement -This statement specifies
  the penalties imposed form is representation,
  falsification or concealment of essential
  information on the Form CMS-485.

72
Medical Update

• Top of page Recipient Name and MID
• Provider name and 7100___
• Additional insurance coverage in addition to
  Medicaid including private insurance. Explain
  coverage.
• Last Approval period
• Physician
• Updated information-Please do not re- state
  orders. Summarize care and any new or changes in
  orders. Example 5.5 Shiley changed every 2 weeks
  by SN and CG without difficulty. No unplanned
  trach changes in the last 60 days. Suctioned
  every 2 hrs. with 8 suction catheter for mod.
  amt of yellowish secretions. Scheduled nebs bid
  and required prn nebs x 3 this cert period for
  increased secretions. MD aware and PO antibiotics
  ordered. 20 Foley changed every other month. No
  s/sx of UTIs.

73
Medical Update Continued

• Weight
• Date of last exam by MD
• Changes in condition-can state see above
• Home safety and environment-Include caregivers
  who they are and any safety concerns.
• Critical Incidents-Falls ,Hospitalizations,etc
• Therapies currently receiving and frequency
  PT,OT,play therapist
• Emergency Plan when nurse not available-Please
  list available and trained caregivers
• Training needs
• Education provided and on-going needs

74
Hourly Nursing Review Criteria

• Technology needs
• Vent dependent
• Tracheostomy no vent
• CPAP/BIPAP-no trach
• Hospitalizations
• Skilled Care needs
• Endotracheal Suctioning-frequency
• Sterile Dressing-Do not include trach site
  dressing
• NG/GT/GJ tube feedings- For continuous points
  must have feedings over at least 8 hours. Points
  for reflux must be on medications for GERD or
  swallowing study.
• IO-Ineligible for points unless intervention
  such as adjustment to tube feedings.
• Intermittent catheterization.

75
Hourly Nursing Review Continued

• 6.Intravenous Fluids,medications,or
  nutrition-baseline not when ill
• 7.Pulse Oximetry,CO2 monitoring,nebs,chest PT-can
  not receive more than 8 pts. No matter how many
  recipient receives..
• 8. Medication-Moderate and Complex pts. Include
  those that are prn and require adjustment by the
  nurse. Must be more than 3 given in a 8 hour
  period.
• Activities of Daily Living Needs-Age Appropriate
• Naso orophargeal suctioning.
• Dressing/site care-not trach dressing
• Oral /feeding assistance
• Recording intake and output
• Incontinence care
• Personal care
• Range of Motion
• Ambulation/transfer/bed mobility

76
Hourly Nursing Review Continued

• Home Environment/Caregiver Information
• Include caregiver health issues, other programs,
  stressors,etc. If on CAPMR provide case-manager
  name and contact information.
• Questions?