Date of Adoption: May 4, 2001.

Purpose: To develop rules for private duty nursing for persons eighteen years of age and older. Rules for private duty nursing were formerly included in medical assistance administration rules, which now apply only to children, new WAC 388-71-0900 to 388-71-0965.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 42 C.F.R. 440.80.

Adopted under notice filed as WSR 01-07-044 on March 15, 2001.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 14, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 14, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 14, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

May 1, 2001

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (1) Describe the eligibility requirements under which an adult age eighteen and older may receive private duty nursing (PDN) services through aging and adult services;

     (2) Assist clients and families to support clients in their own homes; and

     (3) Describe the requirements applicants/clients families, home health agencies, and privately contracted registered nurses (RNs) and licensed practical nurses (LPNs) must meet in order for services to be authorized for PDN.

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     (1) Is an optional community-based Medicaid service for adults eighteen or older with complex medical needs who require at least four continuous hours of skilled nursing care on a day to day basis;

     (2) Provides an alternative to institutionalization in a hospital or nursing facility; and

     (3) Is a resource of last resort and is not intended to supplant or replace other means of providing the services.

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     (1) Meet Medicaid requirements under the:

     (a) Categorically needy program; or

     (b) Medically needy program.

     (2) Use private insurance as first payer, per Medicaid rules. Private insurance benefits which cover hospitalization and in-home services must be ruled out as the first payment source to PDN.

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     (1) Be assessed by a CNC as requiring care in a hospital or meeting nursing facility level of care, as defined in WAC 388-71-0435(4).

     (2) Have a complex medical need that requires four or more hours of continuous skilled nursing care which can be safely provided outside a hospital or nursing facility; and

     (3) Are technology-dependent daily, which means you require at least one of the following:

     (a) A mechanical ventilator or other respiratory support at least part of each day;

     (b) Tracheostomy tube care/suctioning;

     (c) Intravenous/parenteral administration of medications; and

     (d) Intravenous administration of nutritional substances.

     (4) Require services that are medically necessary.

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     (1) A CNC must use the comprehensive assessment (CA) to assess:

     (a) Unmet skilled care needs;

     (b) Informal supports; and

     (c) Other services paid for by the department.

     (2) Your primary care physician must:

     (a) Document your medical stability and appropriateness for PDN;

     (b) Provide orders for medical services; and

     (c) Document approval of the service provider's plan of care.

     (3) You must also:

     (a) Be able to supervise your care (provider) or your guardian must be available on the premises; and

     (b) Have family or other appropriate support who is responsible for assuming a portion of your care.

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     (2) You may be required to pay participation if you are receiving home and community program services, as described in WAC 388-71-0405 and 388-71-0470.

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     (1) A Washington state licensed and contracted home health provider can provide your PDN services.

     (2) With an approved exception to policy (ETP), a private (nonhome health agency) registered nurse (RN) or licensed practical nurse (LPN) under the direction of the physician can provide your PDN services only when:

     (a) The geographic location precludes a contracted home health agency from providing services to you; or

     (b) No contracted home health agency is willing to provide PDN services to you.

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     (1) Your PDN cannot exceed sixteen hours a day. The hours are determined through a CA completed by a CNC;

     (2) Trained family must provide for any hours above your assessment determination, or you or your family must pay for these additional hours;

     (3) In instances where your family is temporarily absent due to vacations, PDN must be:

     (a) Paid for by you or your family; or

     (b) Provided by other trained family. If this is not possible, you may need placement in a long-term care setting during their absence.

     (4) You may use respite care if you and your unpaid family caregiver meet the eligibility criteria defined in WAC 388-71-1075.

     (5) You may receive additional hours, up to thirty days only when:

     (a) Your family is being trained in care and procedures;

     (b) You have an acute episode that would otherwise require hospitalization;

     (c) Your caregiver is ill or temporarily unable to provide care; or

     (d) There is a family emergency.

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     (1) Be licensed and contracted by Washington state. A license is obtained through the department of health. A contract is obtained through aging and adult services administration;

     (2) Have physician orders;

     (3) Have a detailed service plan, including time sheets, that is reviewed at least every six months by the physician and CNC case manager;

     (4) Submit timely and accurate invoices to the social services payment system (SSPS).

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     (1) Have a license in good standing;

     (2) Complete a contract;

     (3) Provide services according to the service plan under the supervision/direction of a physician;

     (4) Complete a background inquiry application. This will require fingerprinting if the RN or LPN has lived in the state of Washington less than three years;

     (5) Have no conviction for a disqualifying crime, as stated in RCW 43.43.830 and 43.43.842;

     (6) Have no stipulated finding of fact, conclusion of law, an agreed order, or finding of fact, conclusion of law, or final order issued by a disciplining authority, a court of law, or entered into a state registry with a finding of guilt for abuse, neglect, abandonment or exploitation;

     (7) Complete time sheets monthly;

     (8) Document notes regarding your services provided per the service plan, which are reviewed at least every six months by the CNC case manager; and

     (9) Submit timely and accurate invoices to SSPS.

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     (1) Have an approved exception to policy;

     (2) Possess a WA state registered nurse license;

     (3) Sign a contract amendment stating they will ensure twenty-four-hour personal care and nursing care services pursuant to the Nurse Practice Act;

     (4) Provide the PDN services to you. Your service plan cannot exceed a maximum of eight PDN care hours per day;

     (5) Have a nursing service plan prescribed by your primary physician that allows you to reside in an AFH. The physician is responsible for:

     (a) Overseeing your plan of care;

     (b) Monitoring your medical stability; and

     (c) Supervising the safety of the AFH's nursing care services.

     (6) Keep records and have your service plan reviewed at least every six months.

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