Private Duty Nursing is defined as skilled nursing services provided by an RN or LPN on an hourly basis. Skilled nursing services are defined as medically necessary services, ordered by a physician, which must be delivered by licensed, skilled personnel to ensure patient safety and achieve medically desired results. Services must require the professional proficiency and skills of an RN or LPN. The decision to use RN or LPN is dependent on the type of services required and must be consistent with the scope of nursing practice under applicable state licensure regulations. Private duty nursing performed by an LPN must be under supervision of an RN following a plan of care developed by the physician in collaboration with the individual, family/caregiver and private duty nurse.
NOTE: The provision of a service by skilled personnel does not necessarily render the service skilled. It is the service itself that dictates whether the care is skilled or non-skilled.
- Reasonable and necessary services as defined below:
- Provide maintenance care by family members, health aides or other unlicensed individuals after an acute medical event when an individual has reached the maximum level of physical or mental function and is not likely to make further significant improvement.
- Provide treatment consisting of custodial care, respite care, or other services that are desired because of the unavailability or caregiver(s).
- Perform activities not requiring intervention by skilled personnel.
- Assist activities of daily living such as walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, establishing bowel programs, preparing special diets, managing established enteral feedings, etc. primarily for the purpose of meeting personal rather than medical needs, which is not specific therapy for an illness or injury and is not skilled care.
- Private duty nursing is not considered medically necessary when one or more of the following are met:
- Supervise ongoing treatment.
- Identify complicating factors and/or comorbidities through required frequent evaluations and monitoring.
- Ensure patient safety
- Private duty nursing services are considered medically necessary when all of the following conditions are met:
- One of the severity of illness evaluation and management criterion needs to be applied to all requests for private duty nursing services. When information provided establishes medical necessity based on the notes listed below, the case manager is authorized to approve the case. If the submitted information does not meet established criteria, the case manager should refer the request for service to a physician advisor to make a necessity determination.
- Private duty nursing services are designed to accomplish medically necessary, cost effective management of acute and complex clinical conditions, in which there is a realistic expectation that within a finite and reasonable period of time, the caregiver will be knowledgeable, independent and safe in providing the established plan of care.
- The services must be skilled and not custodial in nature.
- The patient’s condition would require skilled inpatient care, if not for the availability and provision of intensive care services in the home.
- The patient’s need for skilled care is greater than what can be provided under a standard home health care program.
- The patient requires a minimum of hourly skilled nursing interventions during each of the hours requested for coverage. Services must be performed on a part-time or intermittent visiting basis, according to the defined treatment plan and under the direction of a physician in order to ensure the safety of the individual and to achieve the medically desired result.
- The severity and instability
- The patient essentially must be confined to his/her home with home confinement defined as considerable and taxing effort needed for the patient to leave home.
- Availability of Caregiver: Private duty nursing is appropriate for short-term training with the intent of having caregivers assume this role when the individual’s medical condition becomes stable. If there is no caregiver available to assume this role, private duty nursing is not appropriate.
- Conditions are not requiring hourly skilled care.
- Custodial level of care, defined as care that serves to:
- Hourly home health aide or homemaker service.
- Constant, individualized skilled nursing care provided in a hospital inpatient setting.
- Skilled nursing services which are not medically necessary for the patient’s medical condition, even if provided on daily basis.
- Solely for convenience.
- Stable medical condition.
- Services to allow the individual’s family to work or to provide respite for the family.
- Services must be consistent with prevailing, accepted standards of medical practice.
- Services must be represent specific and effective treatment for the patient’s condition.
- Services must be of a level of complexity that they can be safely and properly performed only by qualified, licensed, clinical personnel.
- Initially, written weekly private duty nursing notes are required for assessing the need to extend a private duty nursing service, in order to determine if the individual has reached his/her optimal level of recovery and that a caregiver has been taught to assume care.
- For continued requests for private duty nursing, private duty nursing notes with measurable long and short-term goals and a plan of care are required. The frequency of these updates is determined by the case manager, but at least monthly. These updates may be done telephonically at the discretion of the case manager.
- Hourly skilled documentation of the actual time the services are provided to include but not limited to:
Acute mechanical ventilation with:
- Hourly assessment of lung sounds
- Tracheal suctioning at least every 1-2 hours
- Respiratory treatments
- Documentation including a description and amount of secretion, pulse oximetry results, ventilator settings, tracheostomy assessment and care etc.
Acute and complex respiratory care with:
- Hourly assessment of lung sounds
- Tracheal suctioning at least 1-2 hours
- Respiratory treatments
- Documentation including a description and amount of secretions, pulse oximetry results, oxygen rate and route, tracheostomy assessment and care etc.
Acute and complex neurological care with:
- Multiple seizure activity within the hour requiring IM/IV medication administration
- Neurological nursing assessment
- Episodic activity as needed
All members receiving private duty nursing must be case managed. A case management plan of care must be developed with input from the member, caregiver, physician and home health nurse. Home health skilled nursing criteria are not applicable in approving private duty nursing benefits. The authorization of private duty nursing is a separate and distinct function from the authorization of skilled nursing and is performed using the private duty nursing guidelines listed above
It is recognized that, in some circumstances, lay family members and friends can be trained to safely and effectively provide chronic services that are typically considered skilled, e.g. pharyngeal suctioning or gastrostomy feedings.