OAR 410-132-0080: Limitations

(1) General pertains to both shift care and visits: (a) Private duty nursing is not covered if the client is: (A) Twenty-one years of age or older; (B) A resident of a nursing facility; (C) A resident of a licensed intermediate care facility for individuals with intellectual disabilities (ICF/ID); (D) In a hospital; (E) In a licensed residential care facility; (b) Private duty nursing is not covered solely to allow the client's family or caregiver to work or go to school; (c) Private duty nursing is not covered solely to allow respite for caregivers or the client's family; (d) Payment for private duty nursing may not be authorized for parents, siblings, grandparents, foster care parents, significant others, members of the client's household, or individuals paid by other agencies to provide caregiving services; (e) Costs of private duty nursing services are not reimbursable if they are provided concurrently with care being provided under home health or hospice program rules; (f) Home nursing visits as defined in the Home Enteral/Parenteral Nutrition and IV Services rules are not covered in conjunction with private duty nursing services; (g) These services are provided for individuals aged 0 to 21 who need PDN or the same or similar nursing services during school hours. These services are provided through the school-based health services program in conjunction with the individual’s Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP) under the Individuals with Disabilities Education Act (IDEA; (h) Holidays are paid at the same rate as non-holidays; (i) Hours nurses spend in training are not reimbursable; (j) Travel time to reach the job site is not reimbursable; (k) Maintenance care is not reimbursable, except for those individuals in the MFC program. (2) Private duty nursing visit: (a) The nursing care plan and documentation supporting the medical appropriateness for private duty nursing shall be reviewed every 60 days to continue the service for children and adolescents with short-term needs who are served by the Division. Reviews shall be conducted by the responsible unit; (b) Private duty nursing visits are limited to two per day. (3) Private duty nursing shift care: (a) Medically appropriate private duty nursing shift care for clients up to 21years old may be covered for acute episodes of illness, injury, or medical condition up to 60 continuous days in cases where it has been determined that skilled management by a licensed nurse is required; (b) A client may be referred to the MFC program to determine if they meet the criteria for program admission at the time of the initial request for services if any of the following are determined to exist: (A) The client's medical needs are for habilitation or maintenance; or (B) The client's medical needs are long term. (c) Individuals who no longer qualify for private duty nursing shift care shall be referred to the Department for determination of their long-term care needs; (d) The number of hours of private duty nursing services that a client may receive is determined by the score on the Private Duty Nursing Acuity Grid (DMAP 591): (A) The client shall score greater than 60 points on the Acuity Grid to receive up to 24 hours per day immediately after discharge from a hospital or if there is a significant worsening or decline of condition; or (B) The client shall score 50 to 60 points on the Acuity Grid to receive up to 16 hours per day immediately after discharge from a hospital or if there is a significant worsening or decline of condition; or (C) The client shall score 40 to 49 points on the Acuity Grid to receive up to 84 hours per week immediately after discharge from a hospital or if there is a significant worsening or decline of condition; or (D) If the score is 30 to 39 on the Acuity Grid, then the Private Duty Nursing Psychosocial Grid (DMAP 590) shall be used to determine eligibility. If the score is 24 or above, the client may receive up to 84 hours per week of shift care. (e) The banking, saving, or accumulating unused prior authorized hours used for the convenience of the family or caregiver is not covered.