Private Duty Nursing - Protocol_ Private Duty Nursing Community

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					ACCESS ALLIANCE OF MICHIGAN, 5-15-01


                                  COMMUNITY LIVING SUPPORTS
                                      Private Duty Nursing


Covered Service
CLS Private Duty Nursing - Private Duty Nursing (PDN) services consist of nursing procedures to meet an
individual’s health needs that are directly related to their developmental disability. The PIHP must
determine the extent to which the individual’s health as described in Medical Criteria I or II below, require
nursing procedures as described in Medical Criteria III. The PIHP must find that the beneficiary meets the
criteria of either Medical Criteria I and III listed below, or Medical Criteria II and III listed below. PDN
services are necessary to prevent institutionalization. Licensed nurses provide the nursing treatments,
observation, and/or teaching as ordered by a physician prescription, and that are consistent with the written
individual plan of services. These services should be provided to a beneficiary at home or in the
community.

Current AAM Procedure Code:
       Private Duty Nursing (performed by Registered Nurse) – S9123
       Private Duty Nursing (performed by Licensed Practical Nurse) – S9124

Unit Type (Current)
        Hour

Prior Service Activity Code
        CLS Private Duty Nursing- 3047

Eligibility Criteria:
    1. Consumer meets the Michigan Mental Health Code (Act 258 of 1974 as revised in 1996 )
          definition as a person with a Developmental Disability.

    2.   The PIHP must assess and document the availability of all private health care coverage (e.g.,
         private or commercial health insurance, Medicare, health maintenance organization, preferred
         provider organization, Champus, Worker’s Compensation, an indemnity policy, automobile
         insurance) for private duty nursing and will assist the beneficiary in selecting a private duty
         nursing provider in accordance with available third-party coverage. This includes private health
         coverage held by, or on behalf of, a beneficiary.

    3.   Private Duty Nursing is a Medicaid coverage for beneficiaries under age 21 who meet the medical
         criteria for eligibility and, therefore, private duty nursing services covered by this HSW waiver are
         not available to that age group. Refer to the Private Duty Nursing Chapter of the Medicaid Manual
         for additional information.

    4.   The consumer has an expressed outcome relative to independent housing and the maintenance of
         health and safety.

Medical Criteria I – The beneficiary is dependent daily on technology-based medical equipment to sustain
life. "Dependent daily on technology-based medical equipment" means:
          Mechanical ventilation four or more hours per day or assisted respiration (Bi-PAP or CPAP); or
          Oral or tracheostomy suctioning eight or more times in a 24-hour period; or
          Nasogastric tube feedings or medications when removal and insertion of the nasogastric tube
             is required, associated with complex medical problems or medical fragility; or
          Total parenteral nutrition delivered via a central line, associated with complex medical
             problems or medical fragility; or
          Continuous oxygen administration, in combination with a pulse oximeter and a documented
             need for observations and adjustments in the rate of oxygen administration.




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Medical Criteria II – Frequent episodes of medical instability within the past three to six months,
requiring skilled nursing assessments, judgments or interventions (as described in III below) due to a
substantiated progressively debilitating physical disorder.
Definitions:
          "Frequent" means at least 12 episodes of medical instability related to the progressively
              debilitating physical disorder within the past six months, or at least six episodes of medical
              instability related to the progressively debilitating physical disorder within the past three
              months. "Medical instability" means emergency medical treatment in a hospital emergency
              room or inpatient hospitalization related to the underlying progressively debilitating physical
              disorder.
          "Emergency medical treatment" means covered inpatient and outpatient services that are
              furnished by a provider that is qualified to furnish such services and are needed to evaluate or
              stabilize an emergency medical condition.
          "Emergency medical condition" means a medical condition manifesting itself by acute
              symptoms of sufficient severity (including severe pain) such that a prudent layperson who
              possesses an average knowledge of health and medicine could reasonably expect the absence
              of immediate medical attention would result in placing the health of the individual in serious
              jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ
              or part.
          "Progressively debilitating physical disorder" means an illness, diagnosis, or syndrome that
              results in increasing loss of function due to a physical disease process, and that has progressed
              to the point that continuous skilled nursing care (as defined in III below) is required.
          "Substantiated" means documented in the clinical/medical record, including the nursing notes.

For beneficiaries described in II above, the requirement for frequent episodes of medical instability is
applicable only to the initial determination for private duty nursing. A determination of need for
continued private duty nursing services is based on the continuous skilled nursing care.

Medical Criteria III – The beneficiary requires continuous skilled nursing care on a daily basis during the
time when a licensed nurse is paid to provide services.
Definitions:
          "Continuous" means at least once every 3 hours throughout a 24-hour period, and/or when
             delayed interventions may result in further deterioration of health status, in loss of function or
             death, in acceleration of the chronic condition, or in a preventable acute episode.
          Equipment needs alone do not create the need for skilled nursing services.
          "Skilled nursing" means assessments, judgments, interventions, and evaluations of
             interventions requiring the education, training, and experience of a licensed nurse. Skilled
             nursing care includes, but is not limited to, performing assessments to determine the basis for
             acting or a need for action; monitoring fluid and electrolyte balance; suctioning of the airway;
             injections; indwelling central venous catheter care; managing mechanical ventilation; oxygen
             administration and evaluation; and tracheostomy care.
          "Progressively debilitating physical disorder" means an illness, diagnosis, or syndrome that
             results in increasing loss of function due to a physical disease process, and that has progressed
             to the point that continuous skilled nursing care (as defined in III below) is required.
          "Substantiated" means documented in the clinical/medical record, including the nursing notes.

Associated Outcomes
1.      Independent housing accomplished or retained.
2.      Consumer Health and Safety is maintained.
3.      Need for more restrictive interventions is reduced.
4.      Consumer empowered to have greater life control.
5.      Disruptions in service delivery minimized.
6.      Consumer satisfaction with services achieved.




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Typical Service Utilization Pattern
A consumer may receive up to 24 hours per day of CLS Private duty nursing to promote maintenance of an
independent living environment.




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