This section applies to private duty nursing services for eligible clients on fee-for-service programs. Managed care clients receive private duty nursing services through their plans (see chapter 388-538
(1) "Private duty nursing"
means four hours or more of continuous skilled nursing services provided in the home to eligible clients with complex medical needs that cannot be managed within the scope of intermittent home health services. Skilled nursing service is the management and administration of the treatment and care of the client, and may include, but is not limited to:
(a) Assessments (e.g., respiratory assessment, patency of airway, vital signs, feeding assessment, seizure activity, hydration, level of consciousness, constant observation for comfort and pain management);
(b) Administration of treatment related to technological dependence (e.g., ventilator, tracheotomy, bilevel positive airway pressure, intravenous (IV) administration of medications and fluids, feeding pumps, nasal stints, central lines);
(c) Monitoring and maintaining parameters/machinery (e.g., oximetry, blood pressure, lab draws, end tidal CO2
s, ventilator settings, humidification systems, fluid balance, etc.); and
(d) Interventions (e.g., medications, suctioning, IV's, hyperalimentation, enteral feeds, ostomy care, and tracheostomy care).
(2) To be eligible for private duty nursing services, a client must meet all the following:
(a) Be seventeen years of age or younger (see chapter 388-71
WAC for information about private duty nursing services for clients eighteen years of age and older);
(b) Be eligible for categorically needy (CN) or medically needy (MN) scope of care (see WAC 388-501-0060
(c) Need continuous skilled nursing care that can be provided safely outside an institution; and
(d) Have prior authorization from the department.
(3) The department contracts only with home health agencies licensed by Washington state to provide private duty nursing services and pays a rate established by the department according to current funding levels.
(4) A provider must coordinate with a division of developmental disabilities case manager and request prior authorization by submitting a complete referral to the department, which includes all of the following:
(a) The client's age, medical history, diagnosis, and current prescribed treatment plan, as developed by the individual's physician;
(b) Current nursing care plan that may include copies of current daily nursing notes that describe nursing care activities;
(c) An emergency medical plan which includes notification of electric, gas and telephone companies as well as local fire department;
(d) Psycho-social history/summary which provides the following information:
(i) Family constellation and current situation;
(ii) Available personal support systems;
(iii) Presence of other stresses within and upon the family; and
(iv) Projected number of nursing hours needed in the home, after discussion with the family or guardian.
(e) A written request from the client or the client's legally authorized representative for home care.
(5) The department approves requests for private duty nursing services for eligible clients on a case-by-case basis when:
(a) The information submitted by the provider is complete;
(b) The care provided will be based in the client's home;
(c) Private duty nursing will be provided in the most cost-effective setting;
(d) An adult family member, guardian, or other designated adult has been trained and is capable of providing the skilled nursing care;
(e) A registered or licensed practical nurse will provide the care under the direction of a physician; and
(f) Based on the referral submitted by the provider, the department determines:
(i) The services are medically necessary for the client because of a complex medical need that requires continuous skilled nursing care which can be provided safely in the client's home;
(ii) The client requires more nursing care than is available through the home health services program; and
(iii) The home care plan is safe for the client.
(6) Upon approval, the department will authorize private duty nursing services up to a maximum of sixteen hours per day except as provided in subsection (7) of this section, restricted to the least costly equally effective amount of care.
(7) The department may authorize additional hours:
(a) For a maximum of thirty days if any of the following apply:
(i) The family or guardian is being trained in care and procedures;
(ii) There is an acute episode that would otherwise require hospitalization, and the treating physician determines that noninstitutionalized care is still safe for the client;
(iii) The family or guardian caregiver is ill or temporarily unable to provide care;
(iv) There is a family emergency; or
(v) The department determines it is medically necessary.
(b) After the department evaluates the request according to the provisions of WAC 388-501-0165
(8) The department adjusts the number of authorized hours when the client's condition or situation changes.
(9) Any hours of nursing care in excess of those authorized by the department are the responsibility of the client, family or guardian.
[11-14-075, recodified as § 182-551-3000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-551-3000, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090 and 74.09.520. 01-05-040, § 388-551-3000, filed 2/14/01, effective 3/17/01.]