Section 107.12. Private duty nursing services.

 

(1)   Covered services.

(a) Private duty nursing is skilled nursing care available for recipients with medical conditions requiring more continuous skilled care than can be provided on a part-time, intermittent basis. Only a recipient who requires 8 or more hours of skilled nursing care and is authorized to receive these services in the home setting may make use of the approved hours outside of that setting during those hours when normal life activities take him or her outside of that setting. Private duty nursing may be provided according to the requirements under ss. DHS 105.16 and 105.19 when the written plan of care specifies the medical necessity for this type of service.

(b) Private duty nursing services provided by a certified registered nurse in independent practice are those services prescribed by a physician which comprise the practice of professional nursing as described under s. 441.001 (4) , Stats., and s. N 6.03 . Private duty nursing services provided by a certified licensed practical nurse are those services which comprise the practice of practical nursing under s. 441.001 (3) , Stats., and s. N 6.04 . An LPN may provide private duty nursing services delegated by a registered nurse as delegated nursing acts under the requirements of ch. N 6 and guidelines established by the state board of nursing.

(c) Services may be provided only when prescribed by a physician and the prescription calls for a level of care which the nurse is licensed and competent to provide.

(d)

1. A written plan of care, including a functional assessment, medication and treatment orders, shall be established for every recipient admitted for care and shall be incorporated in the recipient's medical record within 72 hours after acceptance in consultation with the recipient and the recipient's physician and shall be signed by the physician within 20 working days following the recipient's admission for care. The physician's plan of care shall include, in addition to the medication and treatment orders:

a. Measurable time-specific goals;

b. Methods for delivering needed care, and an indication of which other professional disciplines, if any, are responsible for delivering the care;

c. Provision for care coordination by an RN when more than one nurse is necessary to staff the recipient's case; and

d. A description of functional capability, mental status, dietary needs and allergies.

2. The written plan of care shall be reviewed and signed by the recipient's physician as often as required by the recipient's condition, but not less often than every 62 days. The RN shall promptly notify the physician of any change in the recipient's condition that suggests a need to modify the plan of care.

(e)

1. Except as provided in subd. 2. , drugs and treatment shall be administered by the RN or LPN only as ordered by the recipient's physician or his or her designee. The nurse shall immediately record and sign oral orders and shall obtain the physician's countersignature within 10 working days.

2. Drugs may be administered by an advanced practice nurse prescriber as authorized under ss. N 8.06 and 8.10 .

(f) Medically necessary actual time spent in direct care that requires the skills of a licensed nurse is a covered service.

(2)   Prior authorization.

(a) Prior authorization is required for all private duty nursing services.

(c) A request for prior authorization of private duty nursing services performed by an LPN shall include the name and license number of the registered nurse or physician supervising the LPN.

(d) A request for prior authorization for care for a recipient who requires more than one private duty nurse to provide medically necessary care shall include the name and license number of the RN performing care coordination responsibilities.

(3)   Other limitations.

(a) Discharge of a recipient from private duty nursing care shall be made in accordance with s. DHS 105.19 (9) .

(b) An RN supervising an LPN performing services under this section shall supervise the LPN as often as necessary under the requirements of s. N 6.03 during the period the LPN is providing services, and shall communicate the results of supervisory activities to the LPN. These activities shall be documented by the RN.

(c) Each private duty nurse shall document the nature and scope of the care and services provided to the recipient in the recipient's medical record.

(e) Travel time, recordkeeping and RN supervision of an LPN are not separately reimbursable services.

(4)   Non-covered services. The following services are not covered services:

(a) Any services not included in the physician's plan of care;

(b) Any services under s. DHS 107.11 ;

(c) Skilled nursing services performed by a recipient's spouse or parent if the recipient is under age 21;

(d) Services that were provided but not documented; and

(e) Any service that fails to meet the recipient's medical needs or places the recipient at risk for a negative treatment outcome.

(f)

1. Except as provided in subd. 2. , services provided by an individual nurse under this section that, when combined with services provided to all recipients and other patients under the nurse's care, exceed either of the following limitations:

a. A total of 12 hours in a calendar day.

b. A total of 60 hours in a calendar week.

2. Services may exceed the limitations in subd. 1. when both of the following conditions are met:

a. The services are approved by the department on a case-by-case basis for circumstances that could not reasonably have been predicted.

b. Failure to provide skilled nursing services likely would result in serious impairment of the recipient's health.

(g)

1. Except as provided in subd. 2. , services provided during any 24-hour period during which the nurse who performs the services has less than 8 continuous and uninterrupted hours off duty.

2. Services may exceed the limitations in subd. 1. when both of the following conditions are met:

a. The services are approved by the department on a case-by-case basis for circumstances that could not reasonably have been predicted.

b. Failure to provide skilled nursing services likely would result in serious impairment of the recipient's health.

Cr. Register, February, 1986, No. 362 , eff. 3-1-86; emerg. r. and recr. eff. 7-1-90; r. and recr. Register, January, 1991, No. 421 , eff. 2-1-91; emerg. r. and recr. eff. 7-1-92; r. and recr. Register, February, 1993, No. 446 , eff. 3-1-93; CR 03-033 : am. (1) (e) Register December 2003 No. 576 , eff. 1-1-04; corrections in (1) (b) made under s. 13.93 (2m) (b) 7., Stats., Register December 2003 No. 576 ; CR 05-052 : r. (2) (b) and (3) (d), cr. (4) (f) and (g) Register June 2007 No. 618 , eff. 7-1-07; corrections in (1) (a) and (3) (a) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636 .