Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-132 - Private duty nursing services under early and periodic screening, diagnostic, and treatment

Current through Register Vol. 40, No. 24, July 15, 2024
A. This section
				  applies to private duty nursing services for eligible individuals in
				  fee-for-service programs. Individuals enrolled with managed care health plans
				  receive private duty nursing services through their plans.
B. Service description. Private duty nursing
				  services are individualized, medically necessary nursing care services
				  consisting of skilled interventions, assessment, monitoring, and teaching of
				  those who are or will be involved in nursing care for the individual. Private
				  duty nursing services under the Early and Periodic Screening, Diagnostic, and
				  Treatment (EPSDT) benefit are provided when appropriate and medically necessary
				  to correct and ameliorate a member's health conditions. As opposed to
				  intermittent care provided under skilled nursing or home health nursing,
				  private duty nursing is provided on a continuous or regularly scheduled basis
				  according to medical necessity. Private duty nursing care provided can be based
				  in the individual's home or any setting in which normal life activities take
				  place. Congregate private duty nursing is defined as private duty nursing
				  provided to two or more individuals who require private duty nursing in the
				  same setting. Services are provided in accordance with
				  42 CFR
				  440.80.
C. Service components. Private duty nursing
				  service is the management and administration of the treatment and care of an
				  individual by a licensed nurse, within the scope of practice as outlined by the
				  Virginia Board of Nursing. Private duty nursing service is not limited to:
1. Assessments (e.g., respiratory assessment,
				  patency of airway, vital signs, feeding assessment, seizure activity,
				  hydration, level of consciousness, constant observation for comfort and pain
				  management);
2. Administration of
				  treatment related to technological dependence (e.g., ventilator, tracheotomy,
				  bi-level positive airway pressure (BiPAP), intravenous (IV) administration of
				  medications and fluids, feeding pumps, nasal stints, central lines);
3. Monitoring and maintaining parameters or
				  machinery (e.g., oximetry, blood pressure, lab draws, end tidal
				  CO2s, ventilator and tube feeding pumps);
4. Interventions (e.g., medications,
				  suctioning, IVs, hyper alimentation, enteral feeds, ostomy care, tracheostomy
				  care); and
5. Exclusions from
				  Department of Medical Assistance Services (DMAS) coverage of private duty
				  nursing services include the following:
a. Not
				  custodial or personal care delivered for the purpose of helping with activities
				  of daily living (ADLs), including dressing, feeding, bathing, or transferring
				  from a bed to a chair, and that can safely and effectively be performed by
				  trained nonmedical personnel;
b.
				  Monitoring for medically-controlled disorders as part of "maintenance of care";
				  and
c. Respite
				  services.