Current through September 24, 2024
A. Nurses providing
private duty nursing (PDN) services must document all nursing care rendered
during each shift including, but not limited to:
1. Current physician's orders,
2. Medications administered and
response,
3. Treatments
administered and response,
4. Any
other professional nursing skills provided during the shift,
5. Narrative skilled nursing services notes
including accurate dates and times of services and documentation that a copy
was given to parent and/or legal guardian or caregiver, and
6. Any significant changes in the
beneficiary's condition,
B. Weekly timesheets must be maintained for
each nurse providing PDN services that include:
1. The date the services were
provided,
2. Begin and end times of
services and a list of services provided during that time,
3. The dated signature of the nurse,
and
4. The dated signature of the
beneficiary's guardian or legal representative.
C. The PDN provider must establish and
maintain a permanent, legible medical record for each beneficiary at the
provider's office which must include, at a minimum, the following:
1. Physician orders updated and signed by the
physician every six (6) months,
2.
Current physician's treatment plan updated every six (6) months,
3. Nursing plan of care (POC) based on the
diagnosis(es), clinical and social status of the beneficiary including
measurable goals updated every six (6) months,
4. Documentation of changes in clinical
status and/or significant occurrences,
5. Weekly progress notes,
6. Monthly summaries must include the
following, at a minimum:
a) Nursing skills
provided,
b) Progress or lack of
progress toward goals,
c) Clinical
and social status of the beneficiary,
d) Current medications and treatments and
changes made during the month, and
e) Changes in the POC.
7. Information regarding other home care
services being provided to the beneficiary including:
a) The specific services provided,
b) Date and times of services, and
c) The providers of the services.
8. Copies of all prior
authorizations.
D. All
records must be maintained and retained in accordance with HIPPA and Medicaid
regulations. [Refer to Part 200, Rule
1.3.]
E. The Division of Medicaid will not
reimburse PDN providers for both PDN and PCS services provided at the same time
to the same beneficiary.
Miss. Code Ann.
§§
43-13-117,
43-13-121.
