Private Duty Nursing (PDN) is the provision of individual and continuous care (in contrast to part-time or intermittent care) provided by a licensed nurse acting within the scope of the Missouri Nurse Practice Act, according to an individualized Plan of Care approved by a physician. Per MO HealthNet Division guidelines, MFAW participants may receive PDN services "when there is a medical need for a constant level of care, exceeding the family's ability to independently care for the participant at home on a long-term basis without the assistance of at least a four (4) hour shift of home nursing care” for each date of service. A Registered Nurse (RN) or Licensed Practical Nurse (LPN) may deliver these medically necessary nursing services. 

The parent(s) and/or responsible party(ies) is the primary caregiver and the PDN is not to take the place of the parent and/or responsible party, with the understanding that the presence of a responsible party(ies) does not obviate the medical necessity of PDN services. It is not permissible for the parent(s) and/or responsible party(ies) to be away from the home for extended periods of time with the expectation the PDN provider agency shall accept total responsibility for the participant, as the intent of the program is to support, not replace, the parent(s)/responsible party(ies). The parent(s) and/or responsible party(ies) must designate an individual to provide direct care and make medical care decisions in the extended absence of the parent(s) and/or responsible party(ies). This designated individual shall not be an employee of the provider agency nor a SHCN employee.

PDN Assessment Tools

The Level of Care Determination Summary, Client Assessment Form, and SCA will be completed by the SC to assist the SC in determining medical eligibility and the level of service authorization that is appropriate to meet the needs of the participant. In addition to these standard tools, the SC may review other sources of information to obtain sufficient understanding of the participant’s care, specific medical needs, and interventions, which may include:

• Physician's orders, plans of care, and/or medical reports,
• Provider progress notes and reports,
• A previous SHCN medical record,
• Documentation of verbal reports from the hospital discharge planners, service provider, Department of Mental Health Case Managers; and/or Family Support Division Case Workers, and
• Evaluation of parent(s) and/or responsible party(ies) strengths and challenges that may affect the ability to provide care for the participant, including a backup caregiver plan in the event that nursing staff is unavailable, by gathering information such as:
  • Family structure,
  • Number of caregivers available,
  • Routine absences of caregiver(s),
  • Number, age, and health status of other household members,
  • Mental and physical health of caregiver(s),
  • Requirement of teaching the caregiver(s), and/ or
  • Willingness of the caregiver(s) to participate in the participant’s care.

The following situations represent examples that would indicate a necessity for PDN:

• Unusual support to sustain vital functions (e.g. oxygen, respiratory support, inhalation therapy, postural drainage),
• Frequent "nursing" monitoring as the result of surgical or medical procedures such as tracheotomies, ileostomies, colostomies, or gastrostomies,
• Continuous maintenance attention because of medical conditions (e.g. frequent suctioning, gastrostomy feedings, etc.), and/or
• Monitoring of vital functions because of threatening episodic events (e.g. seizures, requiring intervention, apnea, arrhythmias).

PDN Assessment Process

Assessment and service planning are continuous activities that begins when the referral/application is received and continues throughout the time the participant receives services. The SC must complete the SCA and all required forms, (including, but not limited to, the MFAW PDN Acceptance Form, Level of Care, and Client Assessment Form) during a face-to-face home visit with the participant, parent(s), and/or responsible party(ies) within 10 business days of the receipt of the referral. The SCA must be completed initially, annually, and when warranted due to changing participant circumstances.

Information obtained during the SCA and routine home visits will be used in the development of the service plan. During the home visit, the SC will:

• Conduct an interview (using the SCA and home visit template) with the participant, parent(s), and/or responsible party(ies) to obtain assessment information,
• Identify services that the participant is currently receiving,
• Explain the applicable MO HealthNet services that may be authorized through the MFAW Program,
  • Evaluate the participant/responsible party(ies) backup plan for when PDN services are unavailable,
  • Assess the eligibility for authorization or referral for other available 
    MO HealthNet services, such as personal care (understanding that PCA services cannot replace PDN services), medical equipment and supplies.
• Document all reasonably foreseeable barriers to the participant’s receipt of authorized PDN hours and all steps that will be taken by SCs, parent(s) and/or responsible party(ies) to address barriers to the participant’s receipt of all authorized PDN hours,
• Complete all forms related to the type of service the participant requires,
• Have participant, parent(s), and/or responsible party(ies)sign any form requiring signatures,
• Determine if additional external supportive services are needed and offer to assist families in connecting to these resources,
• Provide information about other resources and make referrals for services that may be helpful to the participant, parent(s), and/or responsible party(ies), including contact names, addresses, and telephone numbers, as outlined in the home visit template and
• Assist family in locating a provider agency(ies), as outlined below in ‘Provider Selection’

When the SCA and the home visit have been completed, the SC will:

• Enter the SCA information into the SHCN Information System
• Document the home visit using the appropriate template and contact type in the SHCN Information System

Based on the data gathered above and in discussion with the participant, parent(s), and/or responsible party(ies), the SC determines the frequency, amount, and duration of services needed to support the medical needs of the participant. If services are deemed necessary, the SC will prior authorize a minimum of a continuous four hour shift of private duty nursing care per day. It is the policy of MO HealthNet and SHCN that 448 units (112 hours) per week is the maximum amount of private duty nursing services that may be authorized. Exceptions to the policy can be made on a short term basis not to exceed three consecutive weeks or with the notification of the SHCN RC and approval of the MFAW PM when there is documentation to support this need.

• If the authorized PDN exceeds 112 hours/week, the SC must complete a PM Change Request to be reapproved annually with each SCA.

PDN services are authorized as a total number of units per month, based on weekly hours, which are determined by the assessed medical needs of the participant. The participant/responsible party(ies) may schedule services through the provider to meet their needs/schedule throughout the week. The participant/responsible party(ies) must be encouraged to stay within the monthly authorized units. Monthly service authorizations will be based on a maximum of 112 hours per week unless otherwise authorized by the BSHCN, as indicated above. Requested increases in authorizations due to misutilization of the authorized monthly units will not be approved by BSHCN. Participants/responsible party(ies) will need to contact their Service Coordinator to notify them of any status changes that would necessitate a requested change in authorized monthly units.

Required forms for Private Duty Nursing

• SCA (Annually)
• Level of Care (Every six months)
• Client Assessment Form (Every six months)
• DHSS Notice of Privacy and Privacy Policies Acknowledgement (Annually)
• Authorization for Disclosure of Consumer Medical/Health Information (As Necessary)
• Rights and Responsibilities (Annually)
  • Prior Authorization Form (PA) (Every six months)
• Confirmation of Verbal Authorization (Initially, annually and with changes to authorization)
• Expectations For In-Home Services (Signed annually and copies given quarterly)
• MFAW PDN Acceptance Form (Annually)
• Services/Participant Preferences Form (Initially, annually, and with changes to authorization)

Program Manager Authorization Approval

A PM change request is completed for a variety of reasons which include, but are not limited to:

• Any change in authorized PDN services,
• The authorization for services exceeds 112 hours/week, including PRN hours
  • PM Change Requests are not required for the addition of PRN hours that are authorized solely to be shared between multiple providers for shift coverage purposes and worded as such that the overall authorization should not be exceeded between the providers
  • If a participant’s authorization exceeds 112 hours/week, a PM Change Request must be approved annually at the time of the participant’s SCA

The SC completes all the sections of the PM Change Request form and submits it to the RC. The RC assigns it to another SC for peer review, as needed. The PM Change Request is then returned to the RC for review and recommendations. The RC will send the PM change request to the MFAW PM and copy the Associate Bureau Chief for review and approval.  When applicable, the original PM Change Request form will be used to complete required updates for re-approval. Re-approval to continue the current authorization should only be submitted annually at the time of the SCA visit. The information on the new addendum will be designated by documenting in a different color corresponding to the date of the new request. Every addendum submitted must address each section of the document.

Provider Selection

The SC will provide the participant, parent(s), and/or responsible party(ies) with a regional provider list that includes current agency contact information.

• The participant, parent(s), and/or responsible party(ies) will select a provider agency within 30 days of receipt of the provider list.
• When initially providing the list, the SC will offer to assist the participant/responsible party(ies) with connecting with provider agencies in their region, if such assistance is needed.
• If the participant, parent(s), and/or responsible party(ies) has not chosen a provider agency in 30 days, the SC will contact the family to offer further assistance with provider selection. If assistance is requested, the SC will inquire with provider agencies regarding staffing availability.
  • Offer for SHCN staff to send an email blast to provider agencies in the participant’s region
  • Communicate the response(s) from provider agency(ies) to the participant, parent(s), and/or responsible party(ies) for provider selection
• The participant, parent(s), and/or responsible party(ies) is considered to have selected a provider agency when they inform the SC of the name of the agency with whom they are working to secure a PDN and set a schedule for PDN services. The provider agency’s inability to staff or fully staff a participant’s required PDN services shall not be considered a failure to select a provider agency.
• If the participant, parent(s), and/or responsible party(ies) has not selected a provider agency in 90 days of receipt of the provider list, ongoing good faith efforts are not being made by the participant and/or responsible party(ies), and sustained efforts have been made by the SC to assist the participant with selecting a provider agency, SHCN will close the case and send a closure letter.

Service Authorization

Once a provider agency is chosen by the participant, parent(s), and/or responsible party(ies), the SC contacts the provider agency to discuss the service authorization. A MFAW Confirmation of Verbal Service Authorization (VC) is sent to the provider agency to be signed and returned to SHCN. This form is filed in the participant’s chart. The paid service enrollment date is the date that in-home services are authorized to begin and/or on the participant’s 21^st birthday. The enrollment screen is updated to reflect the change in status from ‘service coordination’ to ‘paid services’. An updated VC will be sent with any change in service authorization.

Plan of Care

The provider agency is responsible for developing a Plan of Care and obtaining the physician’s signature. The Plan of Care specifies the type, frequency (number of 15 minute units per day or per week) and duration (how many weeks or months) of services and DME supplies to be provided. The Plan of Care must also include the specific skilled nursing procedures to be completed. The provider agency is responsible for submitting the Plan of Care to SHCN that must be signed by a physician or the provider agency registered nurse indicating receipt of a verbal order from the physician. The Plan of Care needs to include the following elements:

• Reviewed and re-established by the physician at least every 60 days,
• Changes to frequency or type of services authorized during a certification period must be approved by the physician by way of verbal or written order,
• All pertinent diagnoses, including mental status, types of services, supply list frequency of services, prognosis, medications and treatments, safety measures to protect against injury, and discharge plans (where applicable),
• Frequency and duration of services including the type of professional to provide the authorized services, and
• Address short term as well as long term nature of the care required.

Upon receipt of this documentation from the agency, the Facilitator and SC will review for accuracy and appropriate content. The Facilitator shall complete the PA form for the authorized services. Upon completion, the SC will sign and date the PA form indicating approval. PDN services may not be authorized for longer than a six month period. The Facilitator emails the original PA form to the DSS, MO HealthNet Division Fiscal Agent for data entry and a copy of the PA form is kept in the participant’s record.

Required Contacts and Home Visits

Initial Home Visit

• The SC completes a SCA during the initial home visit with the participant and parent/responsible party within 10 business days of the date of the referral. The RC or the MFAW PM may grant exceptions to this requirement.

Annual and Routine Home Visits

• The SC completes a SCA annually during a home visit with the participant, parent(s), and/or responsible party(ies). Home visits are required quarterly and the participant must be seen to determine medical necessity for the continuance of MFAW services. It is expected that the participant, parent(s), and/or responsible party(ies)participate in all home visits except in extenuating circumstances in order to review the participant’s current status and discuss any significant changes that may impact the plan of care. The SC will document home visits in the SHCN Information System using the quarterly or SCA home visit template. In addition, at the six month and annual home visits, the Client Assessment and Level of Care (LOC) forms are completed.

Ongoing Identification of Barriers and Assistance with Barrier Removal

At each home visit, the SC should assess and identify any barriers to obtaining PDN services and assist the participant/responsible party(ies) in removing identified barriers, as necessary. Removing barriers may require assessments for other services and/or referrals to other agencies or community resources who might aid in the removal of the identified barrier(s).

The SC should complete the following steps to assist with barrier identification/removal:

• Review PDN services received and authorized and discuss the participant’s needs in light of any gap in service delivery,
• Assess any potential barriers to receipt of authorized PDN hours,
• Provide assistance to families, as necessary, in removing identified barriers consistent with that family’s circumstances and,
• Review progress toward the removal of any barriers previously identified.

Place of Service

PDN services may be provided in the home of the participant, parent(s)/responsible party(ies), or other caretaker. Participants who require and are authorized to receive PDN in the home may utilize their approved services outside the home during the hours when their normal life activities take them outside the home setting. Service delivery outside the home requires the consent of the participant, parent(s) and/or responsible party(ies). The PDN may not drive the participant. It is not permissible for PDN to be authorized solely for activities outside the home and no additional hours of PDN services may be authorized for the exclusive use outside the home.

• Normal life activities in the local community include those types of activities that do not require time away from the home overnight, which include but are not limited to the following:
  • Attending medical appointments, going shopping, attending religious services, going to a restaurant, going to family functions, and going to a movie or a sporting event.
• Authorization of PDN services for overnight travel is required on an individual basis per trip.
  • The SC completes a VC, specifying the approved range of dates for travel, to authorize PDN services to provide medically necessary care for the participant.
  • The provider must ensure that the PDN staff has appropriate licensure for the states in which they will provide the PDN services.
  • Payment will be for the PDN services only and not include travel expenses.
  • No additional hours of PDN services may be authorized for the overnight travel authorization.

Discontinuation of PDN Services

Participant records are closed by the SC for various reasons. In all instances, good faith efforts must be made by the SC, as outlined in the ‘Good Faith Effort’ policy, and documented in the SHCN Information System to show effective service coordination, including efforts to identify and address barriers regarding the ability of the participant and/or responsible party(ies) to meet ongoing MFAW requirements, and when appropriate, successful transition from MFAW services. Reasons for closure may include:

• The participant, parent(s), and/or responsible party(ies) demonstrates an unwillingness to cooperate with MFAW requirements,
• Participant does not meet eligibility criteria,
• Participant, parent(s), and/or responsible party(ies) request closure of MFAW services,
• Unable to locate after good faith efforts,
• Participant becomes institutionalized, or can no longer be maintained in the home utilizing MFAW benefits,
• The participant no longer  requires waiver services,
• The participant’s needs could be better served through another Home and Community Based Services (HCBS) waiver,
• The participant moves out of the state of Missouri,
• The participant is no longer MO HealthNet eligible, and/or
• The participant expires.

Once the determination has been made to close the file, the SC will request a closure letter to be sent indicating the reason for closure along with the closure date, allowing 10 calendar days for response prior to closure. This action will also be documented in the SHCN Information System. Exceptions to the 10 calendar day closure rule include the following:

• Moved out of state – date of move if known; otherwise use the date that staff became aware of move;
• Deceased - date of death if known; otherwise use the date staff became aware of the death.

Discontinuation of the delivery of PDN Services by Provider Agencies

Providers must give notification to the participant, parent(s), and/or responsible party(ies) and SHCN prior to the discontinuation of PDN services. The PDN service provider notifies the participant, parent(s), and/or responsible party(ies) in writing of the decision to discharge a participant and provides a minimum of 21 day notice prior to the discontinuation of services for reasons that include, but are not limited to, the following:

• The participant, parent(s), and/or responsible party(ies) are non-compliant to the agreed upon Plan of Care,
• The provider is no longer able to meet the service needs of the participant, and/or
• The participant, parent(s), and/or responsible party(ies) requests a change.

The PDN provider agency shall advise the SHCN within 72 hours of the participant, parent(s), and/or responsible party(ies)) notification of planned discontinuation of PDN services. The SHCN SC shall assist the participant, parent(s), and/or responsible party(ies) in making appropriate arrangements to locate and transfer care (if possible and necessary) to a new PDN provider agency. The PDN provider shall notify SHCN within 72 hours of closure of a case due to the following circumstances:

• Death of the participant,
• Participant’s admission to a health care facility, and/or
• Participant is no longer in need of care,

Exceptions for Special Circumstances

Hospice:  When a participant is placed on hospice care in the home, PDN services may still be authorized as indicated by medical necessity and must meet the four hour block minimum standard. When the hospice nurse is in the home, the MFAW PDN must not be on the clock during the duration of the hospice nurse visit to avoid duplication of services but may remain in the home during this time and resume providing care once the hospice nurse leaves. The services provided by the hospice nurse are considered to be part of the continuous four hour requirement and do not constitute a break in service.

Exclusions

PDN services are not authorized for a participant receiving inpatient hospital services or residing in a skilled nursing facility, intermediate care facility, or any other institutional setting or health care facility.