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43.4.13.3 Benefits and Limitations
PDN is a benefit for clients birth through 20 years of age and eligible for THSteps-CCP. THSteps-CCP eligibility ends on the day of the client's 21st birthday. If the client's Medicaid ID states "Emergency Care," "PE," or "QMB," the client is not eligible for THSteps or THSteps-CCP benefits.
PDN is nursing services, as described by the Texas Nursing Practice Act and its implementing regulations, for clients who meet medical necessity criteria and who require individualized, continuous, skilled care beyond the level of skilled nursing visits normally prior authorized under Texas Medicaid (Title XIX) Home Health Services skilled nursing (SN).
PDN must be ordered or prescribed by a physician and provided by an RN, an LVN, a licensed practical nurse (LPN), or through RN delegation to a qualified aide (an unlicensed person such as a home health aide (HHA), a medication aide, or a nurse aide as set out by the TAC.
Professional nursing provided by an RN, as defined in the Texas Nursing Practice Act, means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Professional nursing involves:
• The observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes.
•The maintenance of health or prevention of illness.
•The administration of a medication or treatment as ordered by a physician, podiatrist, or dentist.
•The supervision of delegated nursing tasks or teaching of nursing.
•The administration, supervision, and evaluation of nursing practices, policies, and procedures.
•The performance of an act delegated by a physician.
•Development of the nursing care plan.
Vocational nursing, as defined in the Texas Nursing Practice Act, means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Vocational nursing involves:
•Collecting data and performing focused nursing assessments of the health status of an individual.
•Participating in the planning of the nursing care needs of an individual.
•Participating in the development and modification of the nursing care plan.
•Participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual.
•Assisting in the evaluation of an individual's response to a nursing intervention and the identification of an individual's needs.
•Engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse's experience, continuing education, and demonstrated competency.
Professional and vocational nursing care consists of those services that must, under state law, be performed by an RN or LVN as defined by the Texas Nursing Practice Act §301.002. These services include observation, assessment, intervention, evaluation, rehabilitation, care and counseling, and health teaching and are further defined as nursing services in 42 CFR §§409.32, 409.33, and 409.44.
•In determining whether a service requires the skill of a licensed nurse, consideration must be given to the inherent complexity of the service, the condition of the client, and the accepted standards of medical and nursing practice.
•The fact that the nursing care can be, or is, taught to the client or to the client's family or friends does not negate the skilled aspect of the service when the service is performed by a nurse.
•If the service could be performed by the average nonmedical person, the absence of a competent person to perform it does not cause it to be a nursing service.
•If the nature of a service is such that it can safely and effectively be performed by the average nonmedical person without direct supervision of a licensed nurse, the services cannot be regarded as nursing care.
•Some services are classified as nursing care on the basis of complexity alone (e.g., intravenous and intramuscular injections or insertion of catheters), and if reasonable and necessary to the treatment of the client's illness or injury, would be covered on that basis. In some cases, however, the client's condition may cause a service that would ordinarily not be considered nursing care to be considered nursing care. This would occur when the client's condition is such that the service can be safely and effectively provided only by a nurse.
•A service that, by its nature, requires the skills of a nurse in order for it to be provided safely and effectively, continues to be a skilled service even if it is taught to the client, the client's family, or other caregivers.
Qualified aides who are employed by a home health agency may perform simple procedures as an extension of therapy or nursing services under the supervision of licensed providers.
Qualified aide services include the following:
•Obtaining and recording the client's vital signs (temperature, pulse, respirations, and blood pressure).
•Observation, reporting, and documentation of the client's status and the care or service furnished.
•Completing appropriate documentation.
•Assisting with nutrition and fluid intake.
•Reporting changes in the client's condition and needs.
•Assistance with medications that are ordinarily self-administered.
•Exercise.
•Ambulation.
•Range of motion.
•Positioning.
•Safe transfer.
PDN should prevent prolonged and/or frequent hospitalizations or institutionalization and provide cost-effective and quality care in the most appropriate, least restrictive environment. PDN provides direct nursing care and caregiver training and education. The training and education is intended to optimize client health status and outcomes and to promote family-centered, community-based care as a component of an array of service options.
A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply. THSteps-CCP is obligated to authorize all medically necessary PDN to promote independence and support the client living at home.
PDN cannot be authorized for the primary purpose of providing respite care, childcare, activities of daily living for the client, housekeeping services, or comprehensive case management beyond the service coordination required by the Texas Nursing Practice Act.
Supervision and Delegation
All LVNs must be supervised as required by the Texas Nursing Practice Act:
•Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity.
•LVNs must have a licensed resource person (RN, APN, PA, or physician) whom they can reach by telephone or other similar means, but onsite supervision is not required.
RNs can delegate specific tasks, activities, and functions to unlicensed personnel, but such delegation requires supervision and the following as set out by the Texas BON:
•The clients must meet the medical necessity and eligibility requirements for PDN.
•A qualified aide performing skilled services must meet the requirements to provide each skilled service (e.g., Home Health Aide Certification, Medication Technician Certification, Certified Nurse Aide, etc.).
•A qualified aide is expected to maintain and work within the scope of his/her training or licensure during the entire course of the treatment he/she is providing for the client.
•A qualified aide performing as a certified nurse aide/certified medication aide may do additional skilled tasks as delegated by the supervising nurse but must abide by all the rules outlined in the TAC.
In addition to federal, state, and local rules and regulations regarding nurse delegation, RNs delegating to qualified personnel must:
•Make a supervisory visit to the client's residence at least once every two weeks when the qualified aide is providing skilled nursing care to the client.
•Make a supervisory visit to the client's residence at least once every two weeks when skilled nursing care and PT, OT, and/or ST are being provided by the qualified aide.
•Prepare written instructions for the qualified aide regarding the delegated services.
•Maintain written documentation of all supervisory visits in the client's record.
Note: A supervisory visit is not to exceed more than one hour per individual visit.
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