256B.0654 Private duty nursing.
Subdivision 1. Definitions. (a) "Assessment" means a review and evaluation of a recipient's need for home care services conducted in person. Assessments for private duty nursing shall be conducted by a registered private duty nurse. Assessments for medical assistance home care services for mental retardation or related conditions and alternative care services for developmentally disabled home and community-based waivered recipients may be conducted by the county public health nurse to ensure coordination and avoid duplication.
(b) "Complex and regular private duty nursing care" means:
(1) complex care is private duty nursing provided to recipients who are ventilator dependent or for whom a physician has certified that were it not for private duty nursing the recipient would meet the criteria for inpatient hospital intensive care unit (ICU) level of care; and
(2) regular care is private duty nursing provided to all other recipients.
Subd. 2. Private duty nursing services. All private duty nursing services shall be prior authorized by the commissioner or the commissioner's designee. Prior authorization for private duty nursing services shall be based on medical necessity and cost-effectiveness when compared with alternative care options. The commissioner may authorize medically necessary private duty nursing services in quarter-hour units when:
(i) the recipient requires more individual and continuous care than can be provided during a nurse visit; or
(ii) the cares are outside of the scope of services that can be provided by a home health aide or personal care assistant.
The commissioner may authorize:
(A) up to two times the average amount of direct care hours provided in nursing facilities statewide for case mix classification "K" as established by the annual cost report submitted to the department by nursing facilities in May 1992;
(B) private duty nursing in combination with other home care services up to the total cost allowed under section 256B.0655, subdivision 4;
(C) up to 16 hours per day if the recipient requires more nursing than the maximum number of direct care hours as established in item (A) and the recipient meets the hospital admission criteria established under Minnesota Rules, parts 9505.0501 to 9505.0540.
The commissioner may authorize up to 16 hours per day of medically necessary private duty nursing services or up to 24 hours per day of medically necessary private duty nursing services until such time as the commissioner is able to make a determination of eligibility for recipients who are cooperatively applying for home care services under the community alternative care program developed under section 256B.49, or until it is determined by the appropriate regulatory agency that a health benefit plan is or is not required to pay for appropriate medically necessary health care services. Recipients or their representatives must cooperatively assist the commissioner in obtaining this determination. Recipients who are eligible for the community alternative care program may not receive more hours of nursing under this section and sections 256B.0651, 256B.0653, 256B.0655, and 256B.0656 than would otherwise be authorized under section 256B.49.
Subd. 3. Shared private duty nursing care option. (a) Medical assistance payments for shared private duty nursing services by a private duty nurse shall be limited according to this subdivision. For the purposes of this section and sections 256B.0651, 256B.0653, 256B.0655, and 256B.0656, "private duty nursing agency" means an agency licensed under chapter 144A to provide private duty nursing services.
(b) Recipients of private duty nursing services may share nursing staff and the commissioner shall provide a rate methodology for shared private duty nursing. For two persons sharing nursing care, the rate paid to a provider shall not exceed 1.5 times the regular private duty nursing rates paid for serving a single individual by a registered nurse or licensed practical nurse. These rates apply only to situations in which both recipients are present and receive shared private duty nursing care on the date for which the service is billed. No more than two persons may receive shared private duty nursing services from a private duty nurse in a single setting.
(c) Shared private duty nursing care is the provision of nursing services by a private duty nurse to two recipients at the same time and in the same setting. For the purposes of this subdivision, "setting" means:
(1) the home or foster care home of one of the individual recipients; or
(2) a child care program licensed under chapter 245A or operated by a local school district or private school; or
(3) an adult day care service licensed under chapter 245A; or
(4) outside the home or foster care home of one of the recipients when normal life activities take the recipients outside the home.
This subdivision does not apply when a private duty nurse is caring for multiple recipients in more than one setting.
(d) The recipient or the recipient's legal representative, and the recipient's physician, in conjunction with the home health care agency, shall determine:
(1) whether shared private duty nursing care is an appropriate option based on the individual needs and preferences of the recipient; and
(2) the amount of shared private duty nursing services authorized as part of the overall authorization of nursing services.
(e) The recipient or the recipient's legal representative, in conjunction with the private duty nursing agency, shall approve the setting, grouping, and arrangement of shared private duty nursing care based on the individual needs and preferences of the recipients. Decisions on the selection of recipients to share services must be based on the ages of the recipients, compatibility, and coordination of their care needs.
(f) The following items must be considered by the recipient or the recipient's legal representative and the private duty nursing agency, and documented in the recipient's health service record:
(1) the additional training needed by the private duty nurse to provide care to two recipients in the same setting and to ensure that the needs of the recipients are met appropriately and safely;
(2) the setting in which the shared private duty nursing care will be provided;
(3) the ongoing monitoring and evaluation of the effectiveness and appropriateness of the service and process used to make changes in service or setting;
(4) a contingency plan which accounts for absence of the recipient in a shared private duty nursing setting due to illness or other circumstances;
(5) staffing backup contingencies in the event of employee illness or absence; and
(6) arrangements for additional assistance to respond to urgent or emergency care needs of the recipients.
(g) The provider must offer the recipient or responsible party the option of shared or one-on-one private duty nursing services. The recipient or responsible party can withdraw from participating in a shared service arrangement at any time.
(h) The private duty nursing agency must document the following in the health service record for each individual recipient sharing private duty nursing care:
(1) permission by the recipient or the recipient's legal representative for the maximum number of shared nursing care hours per week chosen by the recipient;
(2) permission by the recipient or the recipient's legal representative for shared private duty nursing services provided outside the recipient's residence;
(3) permission by the recipient or the recipient's legal representative for others to receive shared private duty nursing services in the recipient's residence;
(4) revocation by the recipient or the recipient's legal representative of the shared private duty nursing care authorization, or the shared care to be provided to others in the recipient's residence, or the shared private duty nursing services to be provided outside the recipient's residence; and
(5) daily documentation of the shared private duty nursing services provided by each identified private duty nurse, including:
(i) the names of each recipient receiving shared private duty nursing services together;
(ii) the setting for the shared services, including the starting and ending times that the recipient received shared private duty nursing care; and
(iii) notes by the private duty nurse regarding changes in the recipient's condition, problems that may arise from the sharing of private duty nursing services, and scheduling and care issues.
(i) Unless otherwise provided in this subdivision, all other statutory and regulatory provisions relating to private duty nursing services apply to shared private duty nursing services.
Nothing in this subdivision shall be construed to reduce the total number of private duty nursing hours authorized for an individual recipient under subdivision 2.
Subd. 4. Hardship criteria; private duty nursing. (a) Payment is allowed for extraordinary services that require specialized nursing skills and are provided by parents of minor children, spouses, and legal guardians who are providing private duty nursing care under the following conditions:
(1) the provision of these services is not legally required of the parents, spouses, or legal guardians;
(2) the services are necessary to prevent hospitalization of the recipient; and
(3) the recipient is eligible for state plan home care or a home and community-based waiver and one of the following hardship criteria are met:
(i) the parent, spouse, or legal guardian resigns from a part-time or full-time job to provide nursing care for the recipient; or
(ii) the parent, spouse, or legal guardian goes from a full-time to a part-time job with less compensation to provide nursing care for the recipient; or
(iii) the parent, spouse, or legal guardian takes a leave of absence without pay to provide nursing care for the recipient; or
(iv) because of labor conditions, special language needs, or intermittent hours of care needed, the parent, spouse, or legal guardian is needed in order to provide adequate private duty nursing services to meet the medical needs of the recipient.
(b) Private duty nursing may be provided by a parent, spouse, or legal guardian who is a nurse licensed in Minnesota. Private duty nursing services provided by a parent, spouse, or legal guardian cannot be used in lieu of nursing services covered and available under liable third-party payors, including Medicare. The private duty nursing provided by a parent, spouse, or legal guardian must be included in the service plan. Authorized skilled nursing services provided by the parent, spouse, or legal guardian may not exceed 50 percent of the total approved nursing hours, or eight hours per day, whichever is less, up to a maximum of 40 hours per week. Nothing in this subdivision precludes the parent's, spouse's, or legal guardian's obligation of assuming the nonreimbursed family responsibilities of emergency backup caregiver and primary caregiver.
(c) A parent or a spouse may not be paid to provide private duty nursing care if the parent or spouse fails to pass a criminal background check according to chapter 245C, or if it has been determined by the home health agency, the case manager, or the physician that the private duty nursing care provided by the parent, spouse, or legal guardian is unsafe.
HIST: 1986 c 444; 1990 c 568 art 3 s 51; 1991 c 292 art 7 s 12,25; 1992 c 391 s 3-6; 1992 c 464 art 2 s 1; 1992 c 513 art 7 s 50; 1Sp1993 c 1 art 5 s 51-53; 1995 c 207 art 6 s 52-55; 1996 c 451 art 5 s 17-20; 1997 c 203 art 4 s 28,29; 3Sp1997 c 3 s 9; 1998 c 407 art 4 s 29-31; 1999 c 245 art 4 s 50-58; 2000 c 474 s 8-11; 1Sp2001 c 9 art 3 s 29-41; 2002 c 375 art 2 s 17; 2002 c 379 art 1 s 113; 2003 c 15 art 1 s 33; 1Sp2003 c 14 art 3 s 26-28; 2005 c 10 art 1 s 49,50; 1Sp2005 c 4 art 7 s 15-19