N.J. Admin. Code § 10:60-6.3

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:60-6.3 - Services available under Community Resources for People with Disabilities (CRPD) Waiver programs

(a) Except for nursing facility services, all approved services under the New Jersey Medicaid program as described in N.J.A.C. 10:49, Administration, are available under the Community Resources for People with Disabilities (CRPD) Waiver program from approved Medicaid providers.

(b) Waiver services are as follows:

1. Case management: A process in which a professional nurse or social worker is responsible for planning, locating, coordinating, and monitoring a group of services designed to meet the individual health needs of the beneficiary being served. The case manager shall be the pivotal person in establishing a service package.

i. Special Child Health Services (SCHS) units under contract to the New Jersey State Department of Health and Senior Services shall provide case management to children up to the age of 21.

ii. Beneficiaries 21 years of age or older shall be referred for case management services to those sites approved by the Division, in accordance with this Chapter.

iii. Case management shall not be provided when a beneficiary is in an inpatient hospital setting and the stay extends a full calendar month.

2. Private duty nursing is a waiver service provided under the Community Resources for People with Disabilities (CRPD) Waiver for any CRPD waiver beneficiary who meets the eligibility criteria for private duty nursing. Private duty nursing shall be provided in the community only, not in an inpatient hospital setting. The beneficiary shall have a live-in primary caregiver (adult relative or significant other adult) who accepts 24-hour responsibility for the health and welfare of the beneficiary. A maximum of 16 hours of private duty nursing, from all payment sources, may be provided in any 24-hour period. A minimum of eight hours of hands-on care shall be provided by the primary caregiver. There is no 24-hour coverage except for a limited period of time under the following emergency circumstances and when prior authorized by the Office of Home and Community Services:

i. For brief post-hospital periods while the caregiver(s) adjust(s) to the new responsibilities of caring for the discharged beneficiary; or

ii. In emergency situations such as the illness of the caregiver when private duty nursing is currently being provided. In these situations, more than 16 hours of private duty nursing services may be provided for a limited period until other arrangements are made for the safety and care of the beneficiary.

(c) The items and services provided to covered beneficiaries shall be limited in duration or amount depending upon the cost of the service plan under the Community Resources for People with Disabilities (CRPD) Waiver Program. Any limitation imposed shall be consistent with the medical necessity of the beneficiary's condition, as determined by the attending physician or other practitioner, in accordance with standards generally recognized by health professionals and promulgated through the New Jersey Medicaid program.

(d) The need for private duty nursing services is established initially by DHSS upon completion of the PAS-1 and HSDP (10:60-1.7) . The number of hours of private duty nursing included in the service plan is based upon the beneficiary's medical need and the cost of service. The total cost of all services provided through the Community Resources for People with Disabilities (CRPD) Waiver program must be less than the cost of care in an appropriate institution. The need for private duty nursing services and the hours of private duty nursing services may increase or decrease as the beneficiary's medical status changes, and correspondingly, as the service cost cap changes.

1. An individual clinical record shall be maintained for each beneficiary receiving private duty nursing service. The record shall address the physical, emotional, nutritional, environmental and social needs according to accepted professional standards.

2. Clinical records maintained at the agency shall contain at a minimum the following:

i. A referral source;

ii. Diagnoses;

iii. A physician's treatment plan and renewal of treatment plan every 90 days;

iv. Interim physician orders as necessary for medications and/or treatment;

v. An initial nursing assessment by a registered nurse within 48 hours of initiation of services;

vi. A six-month nursing reassessment;

vii. A nursing care plan;

viii. Signed and dated progress notes describing beneficiary's condition; and

ix. Evidence that beneficiary was given information regarding advance directives.

3. Direct supervision of the private duty nurse shall be provided by a registered nurse at a minimum of one visit every 30 days at the beneficiary's home during the private duty nurse's assigned time. Additional supervisory visits shall be made as the situation warrants.

4. Clinical records maintained in the beneficiary's home by the private duty nurse shall contain at a minimum the following:

i. Diagnoses;

ii. A physician treatment plan and interim orders;

iii. A copy of the initial nursing assessment and six month reassessment;

iv. A nursing care plan;

v. Signed and dated current nurse's notes describing the beneficiary's condition and documentation of all care rendered; and

vi. A record of medication administered.

5. Personnel files shall be maintained for all private duty registered nurses and licensed practical nurses and shall contain at a minimum the following:

i. A completed application for employment;

ii. Evidence of a personal interview;

iii. Evidence of a current license to practice nursing;

iv. Satisfactory employment references;

v. Evidence of a physical examination; and

vi. Ongoing performance evaluation.

6. On-site monitoring visits shall be made periodically by Division staff to the private duty nursing agency to review compliance with personnel, recordkeeping and service delivery requirements.

N.J. Admin. Code § 10:60-6.3