PURPOSE: This rule establishes the basis for Medicaid enrollment and reim. bursement of providers of private duty _.-,..,, nursing care for children under Missouri’s Healthy Children and Youth Program. Editor’s Note: The secretary of state has determined that thepublication of this rule in its entirety would be unduly cumbersome or expensiue. The entire text of the material referenced has been filed with the secretary of state. This material may be found at the Office ofthe SecretaryofStateorat the headquarters oftheagencyandisauailable toanyinterested person at a cost established by state law. (1) Service Definition. Private duty nursing is the provision of individual and continuous care (in contrast to part-time or intermittent care) provided according to an individual plan of care approved by a physician, by licensed nurses acting within the scope of the Missouri Nurse Practice Act. Services within the Medicaid private duty nursing program include:

1. (A) Shift care by a registered nurse (RN); and
2. (B) Shift care by 8 licensed practical nurse (LPN).
3. (2) Persons Eligible for Private Duty Nursing Care. Medicaid-eligible children under the age of twenty-one (21) may be eligible for private duty nursing care under the Healthy Children and Youth Program (HCY) when there is a medical need for a constant level of care, exceedingthefamily’s abilitytoindependently care for the child at home on a long-term basis without the assistance of at least a four (4). hour shift of home nursing care per day. Private duty nursing services for children are prior authorized by the Bureau of Special Health Care Needs of the Department of Health.
4. (3) Criteria for Providers of Private Duty Nursing Care for Children.

5. (A) A provider of private duty nursing care must have a valid Medicaid Private Duty Nursing Provider Agreement in effect with the Department of Social Services, Division of Medical Services. To enroll, the applicant must either submit a written proposal, or be a

   Judith K. Moriarty SII‘my Of state

Medicare-certified and Medicaid-enrolled home health agency, or be accredited by Joint Commission for Accreditation of Health Organization (JCAHO), or be accredited by Community Health Accreditation Program (CHAPS). The written proposal (required by agencies who are not Medicare certified, or accredited by JCAHO or CHAPS), must describe the agency and its service delivery system, assure understanding of and compliance with the standards of the Private Duty Nursing Care Program and document the agency’s administrative and fiscal ability to provide the services in accordance with these standards. Proposals will be reviewed by qualified medical staff or designees of the Department of Social Services (DSS).

1. (B) All applicants to provide Medicaid private duty nursing care, enrolling on the basis of a written proposal, may be subject to on-site reviews, performed at the discretion of the department, by DSS staff or designees prior to enrollment. These reviews will monitor compliance with the administrative requirements of the program and service delivery.
2. (C) On-site reviews to monitor compliance with these standards will be conducted at the discretion of the department subsequent to Medicaid enrollment, when Medicaid has reimbursed for services.

3. (D) Agencies found to be out of compliance with the standards set forth in this rule may have a penalty imposed. Penalties may be as follows:

   1. 1. The agency will be required to submit a

written plan of correction, with a follow-up monitoring by DSS staff within ninety (90) days;

1. 2. New prior authorization requests will

not be approved for a specified period of time; Si”d

1. 3. The Medicaid provider enrollment

agreement will be terminated.

1. (4) Administrative Requirements for Private Duty Providers.

   1. (A) The provider shall immediately notify the provider enrollment unit of the Division of Medical Services of anv chance in location. telephonenumber, admi;listrati;eorcorporate telephonenumber, admi;listrati;eorcorporate status. A thirty (30).day written notice to the status. A thirty (30).day written notice to the Division of Medical Services will be required of Division of Medical Services will be required of the provider prior to the voluntary termination the provider prior to the voluntary termination of the provider agreement. -
   2. (B) The provider shall maintain bonding, personal and property liability, and medical malpractice insurance coverage on all employees involved in delivering nurse service in the home.

   3. (C) The provider must have the cauabilitv to prowde nursing staff outside o? reg&r business hour?, on weekends and on holidays to provide servxes in accordance with the plan ,

      m

of care authorized by the Bureau of Special Health Care Needs for each client.

1. (D) The provider must have a policy for responding to emergency situations. Services reimbursed by Medicaid may not exceed the prior authorization approved by the Bureau of Special Health Care Needs, therefore, any emergency situation resulting in service delivery beyond the limits of the prior authorization must be reported in writing to the Bureau of Special Health Care Needs within seventy-two (72) hours.

2. (E) The provider shall have a written statement of the recipient’s Bill of Rights, which shall be given to the caretaker (if the recipient is a minor) at the time the service is initiated. At a minimum, the statement should sav that the reciuient has the rieht to the foilowing: .

   1. A. Be treated with respect and dignity;
   2. B. Have all personal and medical infor-

mation kept confidential;

1. C. Have direction over the services

provided, to the degree possible, within the service plan approved by the Bureau of Special Health Care Needs;

1. D. Know the provider’s established

grievance procedure and how to make a complaint about the service and receive cooperation to reach a resolution, without fear of retribution;

1. E. Receive services without regard to

race, creed, color, age, sex or national origin; and

1. F. Receive a copy of this Bill of Rights.
2. (F) The provider shall have a written grievance policy which shall be provided to each recipient or caretaker upon initiation of services. The grievance policy must also include the phone number of the Bureau of Special Health Care Needs and the Division of Medical Services, recipient services unit.
3. (G) Theprovidermustreportallinstances of possible child abuse or neglect to the Child Abuse and Neglect (CA/N) Hotline, l-800-392 3738. Any suspected abuse or neglect by a caretaker, including private duty nursing staff, must be reported according to 210.110- 210.169, RSMo, the Child Abuse Law. Failure toreportbyamandatoryreporter(privateduty nursing staff would be considered mandatory reporters) is a violation of 210.115, RSMo and could be subject to prosecution.
4. (H) The provider must maintain Missouri Corporate Good Standing status with the Office of the Missouri Secretary of State.

1. (5) Qualification Requirements for Private Duty Nursing Direct Care Staff and Supervisors. THIS FORM IS TO BE USED FOR EPSDT (HCY) RELATED SERVICES ONLY

   INSTRUCTIONS FOR COMPLETION

FIELD NUMBER AND NAME - I. 1. 2. 3. 4. 5. 6. 7. 8. 9. II. 10. I,. 12. 13. 14. 15. III. 16. ,7. 18. 19. , ., 20. 21. a*. 23. 24.

I”. 25. 26. 27. 28.

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secretary Of Stat8