Current through Register No. 40, October 3, 2024
For each recipient, PDN service providers shall maintain
complete and timely records as follows:
(a) A written, signed, and dated physician's
or other licensed practitioner's order for care provided, updated and signed
every 60 days, which shall include:
(1) The
recipient's diagnosis, with a description of the severity of the illness or
condition; and
(2) A detailed
explanation of the medical need for PDN, including:
a. The specific nursing services that are
required; and
b. A description of
the specific medical complications necessitating PDN;
(b) A nursing assessment with
information that supports the need for PDN including, but not limited to, the
following:
(1) Recipient identification
information including:
a. Recipient
name;
b. Medicaid identification
number (MID); and
c. Date of
birth;
(2) Contact
information of the recipient's parent, guardian, or primary caregiver including
addresses and phone numbers;
(3)
Private health insurance information including coverage dates;
(4) Information regarding the recipient's
participation in any medicaid program, including medicaid to schools, waiver
programs, and licensed nursing assistant (LNA) services, or participation in
the special medical services program;
(5) Name and contact information of the
recipient's treating physician or other licensed practitioner, including the
primary care physician, and any specialists;
(6) A summary of the recipient's physical and
behavioral health status including:
a. A list
of the recipient's current conditions; and
b. A history of the conditions leading to the
need for PDN;
(7) An
assessment of the recipient's body systems including a medication
profile;
(8) A functional
assessment of the recipient's physical and cognitive status including a list of
any durable medical equipment being utilized;
(9) A description of the household make-up
including the nature of the household member's relationship with the recipient
and their ability and availability to provide care and support to the
recipient;
(10) Information about
the recipient's school participation including the number of hours per week the
recipient attends and whether a nurse or aide is available to assist the
recipient while at school;
(11) The
recipient's emergency plan in the event that the primary caregiver is unable to
provide care; and
(12) Any
additional medical or social information, such as family stressors and their
impact on the mental and emotional health of the recipient that the recipient
wants to provide that supports the need for PDN.
(c) A plan of care documenting the extent of
the recipient's nursing needs, prepared by the PDN service provider, signed and
dated by the recipient's physician or other licensed practitioner, and updated
every 60 days in accordance with
42 CFR
484.60(c)(1);
(d) Nurses' notes that fully document, for
each date of service, the provision of services and the care and treatment
provided to the recipient, including:
(1) The
location of where the care was provided, and the time that the nursing shift
began and ended;
(2) A description
of each nursing service provided, including the type of nursing service, the
time of the service delivery, and the recipient's response to the service so
that an independent reviewer can replicate what happened during the
shift;
(3) Details showing that the
nursing services are consistent with the care plan and orders of the
recipient's physician or other licensed practitioner;
(4) Any adverse findings and, if so, a plan
of action to address those findings; and
(5) The recipient's progress towards
established goals; and
(e) Documentation of a face-to-face encounter
between the recipient's physician or other licensed practitioner and the
recipient within 90 days prior to, or within 30 days following the start of,
the PDN service provision, as established in
42 USC
1395n of the SSA and in accordance with 42
CFR 440.
(See Revision Note at chapter heading He-W 500); ss by
#6134, eff 11-30-95, EXPIRED: 11-30-03
New. #8069, eff 4-17-04; ss by
#10107, INTERIM, eff 4-17-12, EXPIRES: 10-15-12; amd by #10139, eff 7-1-12; ss
by #10186, eff 10-15-12
