Direct Service Administrative Resources



MO HealthNet School-Based ServicePrivate Duty Nursing SummaryCovered ServicesIndividual and continuous care of at least 4-hours in duration within a day (Can be a combination of school and home care.)Services by a RN or LPN acting within the scope of Missouri Nurse Practice Act. Statutory Requirements as related to covered services:School must monitor the overall physical care needs of the student while in the school setting and contact the student’s physician if the student’s condition warrants it.All service must be logged according to time spent on providing a MO HealthNet covered service which is contained in an IEP and Plan of Care. [NOTE: Observation and wait time, participating in IEP meetings, and developing a Plan of Care are not covered; and monitoring health condition and responding accordingly is billable.]Services are billed in 15 minute increments calculated by adding total minutes of private duty nursing services divided into 15 minute units.Student Eligibility CriteriaStudent must be Medicaid eligible on each date of billable serviceStudent must be under age 21 and have an individual MO HealthNet number.Student must have active IEP designating nursing services, one-on-one at school.Student must have a Plan of Care/IEP signed by the Private Duty Nursing Provider (PDNP). An Individual Health Plan (IHP) is referenced in the IEP but not necessarily attached.Plan of CareMust use CMS-485, CMS-486 OR CMS-487 or forms developed by the agency that contains all fields and information on the standardized forms for MO HealthNet participantsMust be developed and signed by the treating physician and Private Duty RN or RN Supervisor.Services must be provided as indicated in the IEP and IHP.Must be evaluated at regular intervals –at least annually or more frequently as changes occur.Must be maintained at the school where services are provided and available for audit.Plan of Care must specify: the diagnosisthe desired outcomethe nature of treatment; scope of the service; the frequency of treatment, i.e. number of minutes per day/per week or per monththe duration of services, i.e. weeks or months or school termlevel of care (LPN or RN) based on acceptable standards of nursing practice and scope of service can be defined in the IEPThe Student’s Medical Record Shall ContainIdentifying information about the student, such as name, birth date, MO HealthNet ID number, name of parent/guardian, and emergency contact information.Copy of the IEP documenting Private Duty Nursing (one-on-one continuous nursing services); the IEP is recognized by MO HealthNet as the official prior authorization (PA).Signed physician’s orders prior to service delivery which must be updated regularly, i.e. as often as the IEP (PA) is revised or whenever the IHP is changed.Consent from the student’s legal custodian for treatment prior to service delivery.Plan of CareDaily documentation of all services provided and any supervisory visits.Documentation of the LPN’s competency demonstration before an RN when the Plan of Care includes the services of an LPN.Documentation that copies of the Participant’s Bill of Rights and District Grievance Policy were given to the parent/guardian and/or to the student, as applicable.Requirements for Nurses Providing Private Duty Nursing ServicesRNs or LPNs must show evidence of current licensure status with MO Board of Healing Arts.Upon initial employment documentation must include two contacts of employment or personal references prior to delivering serviceAll LPNs and RNs must have at least four (4) hours of orientation training prior to service provision. Documented by date, begin and end time and topic. Required Topics to be covered include:General information about MO HealthNet, Private Duty Nursing Program and HCYRelationship of the District to MO HealthNetIEP Process (IEP is the Prior Authorization)Student abuse/neglect indicators and reportingStudent’s rightsStudent’s grievance proceduresRelevant board policiesUniversal precautions as defined by the Center for Disease ControlPrior to delivering services, an LPN must demonstrate competency in each task required in the Plan of Care. The competency demonstration must be conducted by a RN and must be documented in the LPN’s personnel file.All direct care staff must have certification in either CPR or basic certified life-support (BCL)LPNs must be supervised by a RN and shall have a personal visit by a supervisory RN at least once every 60 days, if LPN services are authorized.Supervisory visits by the RN will not be separately reimbursed.Requirements for Supervision of Private Duty Nursing StaffEmploy an RN with three (3) or more years of experience to act as supervisor to Private Duty Nursing staff.At least one (1) year experience shall be in a supervisory position or field of pediatric nursing.Supervisor will be responsible for :case conferences with staff nursesdocumenting the case conferencesassuring the competency of stafftraining, orientation, andannual performance evaluation by RN Supervisor of all nursing staff providing direct care.The evaluation must be maintained in the personnel record.The evaluation must be based on a minimum of two (2) on-site visits with the staff person present.Frequency of supervisory visits:Students receiving Private Duty Nursing care shall have a personal visit by a Supervisory RN at least once every sixty (60) days if the provider of the service is a LPN.Not required if intermittent care by RNSupervisory visits or explanation of why there are no separate supervisory visits must be documented in the student’s file.When Using a Private Duty Nursing Provider AgencyThe District must contact Provider Enrollment at MO HealthNet, using the Provider Update Request form, to add the specialty type of School Based Private Duty Nursing (S4) to the District’s MO HealthNet Provider file. Include on the Provider Update Request form in the comment box the name and NPI of the contracted private duty nursing provider agency.The Private Duty Nursing provider agency must be enrolled with MO HealthNet but cannot bill directly.All Private Duty Nursing requirements as set forth in 13 CSR 70-95 must be met.Billing must be completed by a public school district recognized by the State of Missouri and reimbursement by MO HealthNet will go directly to the public school district.When the District is Providing Direct Private Duty Nursing ServicesThe District must contact Provider Enrollment at MO HealthNet, using the Provider Update Request form, to add the specialty type of School Based Private Duty Nursing (S4) to the District’s MO HealthNet Provider file. Include on the Provider Update Request form in the comment box that the district would like to add the specialty type of School Based Private Duty Nursing (S4).The District must meet the criteria as a Private Duty Nursing agency.The District must submit the School Based Private Duty Nursing Provider Agreement Addendum to MO HealthNet to be reviewed by qualified medical staff of the Department of Social Services.Adequate DocumentationAll services provided must be adequately documented in the medical record.Must retain for five (5) years from the date of service, fiscal and medical records that coincide with and fully document services billed to MO HealthNet.Must furnish and make the records available for inspection or audit by the Department of Social Services or its representative upon request.Failure to maintain adequate documentation may result in recovery of the payments for those services not adequately documented and may result in sanctions to the provider’s participation in MO HealthNet Program. ................
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