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December 2016 Texas Medicaid Provider Procedures Manual

Home Health Nursing and Private Duty Nursing Services Handbook : 4 Private Duty Nursing (PDN) Services - CCP : 4.1 * Services, Benefits, Limitations, and Prior Authorization : 4.1.3 * PDN Providers

PDN services must be provided by a LHHS or LCHHS agency enrolled in Texas Medicaid or by an RN or LVN enrolled independently with Texas Medicaid. PDN providers must comply with all applicable federal, state, and local laws and regulations and Texas Medicaid policies and procedures.
All providers must maintain written policies and procedures for:
PDN providers must only accept clients on the basis of a reasonable expectation that the client’s needs can be adequately met in the place of service. The essential elements of safe and effective PDN services include a responsible adult when the client is a minor child, a contingency plan, a primary physician, competent providers, and an environment that supports the client’s health and safety needs.
The place of service must be able to support the health and safety needs of the client and must be adequate to accommodate the use, maintenance, and cleaning of all medical devices, equipment, and supplies required by the client. Necessary primary and back-up utilities, communications and fire safety systems must be available.
Clients who are 17 years of age or younger must reside with an identified responsible adult who is either trained to provide nursing care or is capable of initiating an identified contingency plan when the scheduled private duty nurse is unexpectedly unavailable.
An identified responsible adult is an individual 18 years of age or older who has agreed to accept the responsibility for a client’s provision of food, shelter, clothing, education, nurturing, and supervision. Responsible adults include, but are not limited to: biological parents, adoptive parents, foster parents, guardians, individuals court-appointed as managing conservators, and other family members by birth or marriage.
An identified contingency plan is a structured process, designed by the responsible adult and the PDN provider, by which a client will receive care when a scheduled private duty nurse is unexpectedly unavailable, and the responsible adult is unavailable, or is not trained, to provide the nursing care. The identified responsible adult must be able to initiate the contingency plan.
The responsible adult’s signature must be on the form acknowledging:
A responsible adult of a minor client or a client’s spouse may not be reimbursed for PDN even if the responsible adult is an enrolled provider or employed by an enrolled provider.
PDN services may be delivered in a provider or client ratio other than 1:1.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.