Home Care Series byTammy Marie Baker RN

Orientation to Homecare 101

Home Care vs Facility Care The Arena Changes

Bathroom

Kitchen

DME: Durable Medical Equipment

Local pharmacy

911/you/ambulance

Steps

Visiting therapists

Home Health Nurse

Dirty Utility roomClean utility room

CSR: Central Supply Room24 hour in house pharmacy

Code Team/ ICUElevators

In house therapist ( PT/OT/Speech & gym)Whole Nursing Team

IV Team Respiratory Therapy Team

24/7

Home Care Facility Care

The Home Care Nurse Nurse

SupplyAcquisition

Nutritional Needs

CaseManager

Bathing, ADL, Personal Care

Transportation coordination

Appointments & School

Home Health Care Arena

Advocacy Physician Home School Travel

NursingCare

Am careADL/ OOB Transfers

Medicationsadministration

FeedsGT/ oral

Wound careTUBE CAREOstomy /Foley

Supplies Physician orders for everything

Procurement AcquisitionsClean Supplies and Equipment

MedicationAdministerReconcile

Reorder/ restock Call MD for reorders Pharmacy Pick up

Call Pharmacy as needed.Pick up meds PRN

Physician

CommunicationRelay for the family and MD

Verbal Orders Written transcribed and signed off.

Letters of medical necessity Prescriptions

Schedule appointmentsArrange Transport

Everything Requires a Physician Order

Home Care Physician orders are the signed 485 POC

485 is signed by DOCS and MD

485 POC is updated / re certified every 60 days

All treatments and Medications must have a physician order

Supplies require MD Prescription for Reimbursement

Supplies may also require a letter of medical necessity with Rx

The homecare Nurse is instrumental in helping the family get supplies through communicating with the Physician

The Home Care care nurse assesses the clients needs and relays them to the Physician. You are the one with the client on a daily basis.

Assessment and Communication are Essential

485 “ THE PLAN OF CARE”

THE 485 IS “THE PLAN OF CARE”

IT IS THE PHYSICIANS ORDERS FOR THE HOME CARE CLIENT

IT DESIGNATES: DIAGNOSIS CODES; ASSESSMENT PARAMETERS; TREATMENTS; MEDICATIONS ; DME EQUIPMENT; ALL WRITTEN ORDERS

IT IS REVIEWED AND UPDATED EVERY 60 DAYS (STATE REQUIREMENT)

THE PATIENT IS REASSESSED BY AN RN AND A VERBAL REPORT IS CALLED TO THE MD POST ASSESSMENT

A VSOC IS OBTAINED AFTER MD IS GIVEN UPDATES/SPOKEN TO

IT MUST BE IN THE CLIENTS HOME CHART and CURRENT DATES EVIDENT FOR STATE COMPLIANCE

Physicians OrdersPhysician must be notified of changes in clients status. You call the Doctor and document the communication.

Verbal orders are taken, written, signed off, and communicated back to the DOCS at Maxim Office within 24 hours by the Home Care Nurse.

All orders from a Physician must be brought to the Maxim office to be entered into the clients MARS and 485 POC by the DOCS.

If the orders are received in physicians office have them faxed directly to our office for speed and accuracy.

Maxim Home Care Chart and Office chart must be kept up to date for Coordination of Care , Accuracy, and Compliance.

Call your DOCS with “ ALL NEW ORDERS”.

Original orders come back to the office with Nurses’ notes

Yellow back up stays on the home chart. The home Chart and the Office Chart should both have the same and current information and orders.

485 The Nurses ResponsibilitiesREAD IT~ LEARN IT~ FOLLOW IT

The Nurse or HHA is responsible for knowing their clients POC

The nurse should document according to the goals and treatments on the POC

Education is geared to Goals and POC oriented

Goals are reviewed and revised and accurate to meet patient needs

DocumentationIt must be legible to be legal and follow Maxim Policy and Procedure.

All nurses notes are to be signed by the nurse legibly with your

Full legal signature & Nursing credentials.

Sign those initials. You earned them. Be proud of them- LPN/RN/CHHA

Documentation must be accurate, objective, precise, and timely.

All nurses notes must be signed by the patient or family member.

This is proof of the nurses care and presence. Exceptions must be assessed by the DOCS.

“It is not Legal or Ethical to sign a clients or family members signature

It constitutes Fraud and is a Felony”

Please read your notes and check them before you have family sign on them

Please double check time in/ time out and dates double check them!

White copies are turned into office weekly / yellow carbon copies remain on the chart

The “NO… no List”

DO not use white out. Do Not Cross out or scribble. DO not write error

Transcription of number ( tracing over to change a number is not allowed)

PDN FLOW SHEET

Time in___time out____: circle( AM/PM) the time you started and check date by calendar

Document full Vital Signs at least once per shift and per MD orders

Check all appropriate boxes per system.

Pain is the 5th vital sign document it

Education: Related to goals /Diagnosis/Medications/discharge planning

Called MD? document call/time and why

Narrative summation of Shift. Subjective ( factual events and patients tolerance of care/activities/procedures.)

How Received in care of__________ and left in care of ___________

Review your own documentation prior to signing and submission for accuracy and error be proactive

notes are written on shift not before or after

Intake/OutputRecord all Fluids/Solids/Nutrition/Excretions/secretions Entering/Leaving the body

Oral solids or liquidsFormulasIntravenousParental NutritionFlushesIrrigationsEnemas

Cerebral Spinal Fluid

Blood/Bile

Mucus/Saliva

Emesis/Vomit

Chest Tube

GT residuals

Purulent drainage

Wound drainage

Wound Vacuums

Hemovac/ Jackson Pratt

Urine/Urostomy

Stool rectal/colostomy

Intake: anything that enters the body Output: Anything that leaves the body

+/= Add up all Intake and output at end of shift

Documentation“ no/no” list

The “NO… no List”DO not use white out.

Do Not Cross out or scribble. DO not write error

NO Transcription of numbers or letter

( tracing over to change a number is not allowed)

X X errorX strodekX

MEDICATION RECONCILIATION

Patients medications are reviewed daily by PDN

Medications must have 5 rights : 1-Right patient ( whose prescription is it?) IDENTIFY THE PATIENT 2-Drug Name 3-Dose with concentration noted4-Route5-Time

( prn must specify the reason pt is on med, re: headache, pain , fever ect?)( concentration ) How many (___mg/ ___ml ) we must have this on every medication

Example: Tylenol ( 325mg/tab ) give 650 mg by mouth bid New medications must have MD orders

Medication changes must be reported to Clinical Supervisor or DOCSMedication profile and Mars must be accurate and reflect all current meds

ALL MEDS ARE SIGNED OFF ON MARSFULL SIGNATURE AND INITIALS AT BOTTOM OF MARS

MEDS NOT GIVEN? CIRCLE YOUR INITIALS AND DOCUMENT WHYMed storage in home:

patients meds must be stored in a safe place and segregated from other family members meds.

Medication expiration dates should be checked. Proper disposal of expired meds and pt education is necessary

Narcotics require a narcotics count sheet and need to be counted daily Sharps precautions for needles. ( sharps boxes are available at local pharmacy)

Transcribing medication ORDERSwhat the skilled nurse should know?

HOW TO WRITE A MEDICATION ORDER

PROPER FORMAT (CONCENTRATION) HOW MANY ( __MG/___ML ) we must have this on every medication

DO NOT USE “CC”

DOSAGE ORDERED : HOW MUCH

FREQUENCY /DURATION

PRN INDICATIONS : SPECIFY THE REASON DRUG IS TO BE GIVEN : IE HEADACHE/ FEVER/ PAIN/CONGESTION ECT....

OXYGEN IS A MEDICATION IT MUST BE LISTED ON MED PROFILE

Example: Tylenol ( 325mg/tab ) give 650 mg by mouth bid

New medications must have MD orders

Medication changes must be reported to Clinical Supervisor or DOCSMedication profile and Mars must be accurate and reflect all current meds

MEDICATION CHARTING

MED PROFILE ON EACH CHART FROM ADMISSION, UPDATED PRN AND AT RE -CERTIFICATIONS; SIGNED BY NURSE AT SUPERVISIONS EVERY 30 DAYS; NEW PROFILES NEEDED WHEN MEDS CHANGE

ADMISSION MED PROFILE REQUIRES DATES OFF PRESCRIPTION BOTTLES NOT DATE OF ADMISSION

MED PROFILE REQUIRES MED CLASSIFICATIONS FOR EACH MED

MED PROFILE SIGNED OFF DAILY BY RN INITIALS IN BOXES ONLY IF GIVEN

DO NOT SIGN OUT MEDS GIVEN BY FAMILY ( NOT LEGAL)

DO NOT SIGN OUT MEDS GIVEN BY ANYONE OTHER THAN YOUR SELF.

FAMILY DOES NOT SIGN MARS

NURSE MUST DATE/TIME/INITIAL IN BOX FOR EACH MED GIVE

RECONCILIATION SIGN THE MEDS MATCH THE MD ORDERS WHEN NEW MARS RECEIVED

MED ADMINISTRATIONS SHEETS COME BACK TO OFFICE WHEN COMPLETED AT END OF WEEK.

Ethics“THE UNWRITTEN RULES OF LIFE THAT KEEP BALANCE “

LIVE BY THE RULES....

eth⋅ics  [eth-iks] • –plural noun • 1.(used with a singular or plural verb ) a system of moral

principles: the ethics of a culture.• 2.the rules of conduct recognized in respect to a particular class

of human actions or a particular group, culture, etc.: medical ethics; Christian ethics.

• 3.moral principles, as of an individual: His ethics forbade betrayal of a confidence.

• 4.(usually used with a singular verb ) that branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions.

ETHICS ARE AN INTEGRAL AND IMPERATIVE COMPONENT IN NURSING

ETHICS ARE NON NEGOTIABLE ETHICS GO “HAND IN HAND WITH COMPLIANCE”

AND QUALITY OF CARE

Client Relationship Boundaries• You are a guest and a caregiver in the clients home

• Respect the client and families personal space.

• Allow the family their Privacy

• Do not interfere with in family “personal business”; Stay out of family quarrels and finances

• Respect bath room privacy knock or state is anyone in there before entering

• Refrain from eating the clients food

• Request permission to use kitchen, microwave of refrigerator

• Respect cultural boundaries and customs.

• Maintain a professional relationship

Cultural DiversityRESPECT~UNDERSTANDING ~ EDUCATION

• Cultural Diversity must be observed at all times.

• Not all cultures practice their beliefs, do not assume observe

• Education on the particulars of the families cultural and religious beliefs is essential

• If your not familiar with the families culture ask your supervisor or Director for help

• Different cultures speak different languages; dress differently; eat different foods, view medical needs differently; experience pain and needs differently as nurses

• Different cultures are offended by gestures, eye contact ; showing of skin; clothing

hand shaking etc

ACCEPT~UNDERSTAND~REACH OUT

SAFETY IN THE HOME“We are the Safety police”

Assess the home upon admission and routinely for Safety Factors, problems and needs:

• Assess the clients home for Safety issues.• Body Mechanics for client and Staff• Is the clients bed safe is it a good height for the client and nurse• Bathroom safety: Bars , commode lifer, non slip surface mats• Kitchen Safety: safe stove , pot handles in, burners working• Are extension cords safe or a fire hazard ( frayed, worn, over loaded)• Does the client have a working phone • Does the client have electric and running water• Are smoke and fire distinguishers present• Are the medications stored separately, with in dates and not expired, out of reach of small children and elderly• Are floors clear of clutter, throw rugs to prevent falls and tripping accidents• Lifting safety? Is the client able to walk, transfer or do they require a lift. • Ramps and house access for disabled • Abuse Risk assessments elderly, small children and disabled

Pediatrics/Child Proof?

Electrical plug covers

Stove handle covers, pot handles inward

Medicine safety lids and out of reach

Poison control hot line # present

Bed rails or crib rails, gates up

Tub safety, never leave unattended

Water temp checked prior to bath

Documentation Accountability

• Nurses give report and get report• Please indicate who you picked up the client from and

how you received report• Please document whom you left the client in care

of .There is a box for this on the flow sheet at the bottom.

• Family or client must sign flow sheet at the end of shift.

Samples:

1) Baby Billy was received in the care of mom. Mom States Baby Billy had a good day with O2 sats at 98%.

2) Jimmy Joe was received from Nurse Nancy. Verbal report given.

3) Karen resting in bed, side rails up, no apparent distress noted.

4) Suzie Q was left in care of Uncle Sam and resting comfortably in bed.

Durable Medical Equipment“DME”

Your DME is your clients medical equipment supplier / What constitutes DME?

Examples: Wheel chairs, Canes, Hospital beds, Hoyer lifts ,Medical strollers, Special Needs Car Seats, Standers, Shower Chairs, Ventilators, Trach’s, Suctions Catheters, Nebulizer Machines, Pulse Oximeters, Coughalaters, Gloves, Gauze, Tape, Diapers, Tube Feed Supplies, GT Formula, Pumps, Feeding tubes, air mattress, ostomy supplies, Foleys, Shower bars, Commode Elevation Seats, Commodes, Tens Units , Orthotics –Braces, AFO’s, Body Jackets, Neck Supports, Wrist Splints, Swath, any type of orthotic brace.

A client may have more than one DME supplier?Respiratory, Orthotics, Seating and Adaptive Equipment.

It is important to keep a list of suppliers and what they supply to the client.All DME is prescribed by a MD. They will write a Rx and may add a a LOMN

( letter of Medical Necessity) to acquire the position.

DME Cleaning

All equipment should be cleaned and maintained. Sanitation of equipment is done by wiping down equipment daily

and then soaking equipment for 20 minutes once a week in a

10 % solution of vinegar and water.

(1oz vinegar to 10 oz water)

• Submerge items in solution for specified length of time 15-20 minutes twice week. • Remove disinfected items from basin and rinse in water. • Air dry or dry with paper towels before storing. • Store in clean, dry, dust-free environment, e.g., plastic, ziploc bag, or lidded jar . •. Discard solutions into toilet, wash basin with soap and water, rinse and dry with paper towels.

ON the Clients Home Chart

• Current 485 present• HIPAA • Emergency Plan /Numbers• Advanced Directives• Falls Precautions• History and physical • Physicians Orders signed off and sent in

to the office• Nurses notes• MARs & Med Profile current

Emergency Plan and Numbers

• Client must have an emergency plan for evacuation.• Client must have emergency numbers on chart.• Nurse must be able to safely evacuate client if needed. • Consideration: mobility or lack of, equipment O2/ vents,

wheelchair ramps etc.• Know the county emergency numbers/ Disaster plan. • Power outage: Flash light, batteries, generators and back

up vent ready; evacuate if no power and unsafe.• Keep back up equipment charged at all times for

Emergacny

Death and Dying in the Home

• Know patient code status, living will etc.

• Respect family wishes

• Full code- initiate CPR and call 911

• If the DNR (signed by MD ) is NOT in writing, it is a FULL code no matter what the family wishes are.

• “NO CODE” support and respect client

• Post mortem care per family wishes

WHO TO NOTIFY:

911; Client Physician; HHA Office, Direct Supervisor; Director of Nursing.

NEW CASE MEMO:

• Do not take a case with out talking to the DOCS or your clinical supervisor

• You must be given clinical report first from a clinician. Report maybe by phone in office or in person but must come from DOCS or CS ( A Clinician not a recruiter)

• First case is oriented in the home on first shift with a Clinical Supervisor

• Nurses must be comp’d on the case prior to or on first shift.(Skills Lab & in home)

• Do not take a wellness clinic with out Comp’s : SEE THE DOCS FIRST• If you are asked to staff a case you must give a definite YES or NO• YES: I will take the case or NO: I can not. • All sick calls should be made at least 4 hours prior to shift.• Frequent call outs are not acceptable. Our clients are expecting a nurse

for care and it is not professional to not show up, not call or not call out in an appropriate time manor. Remember that a sick client is counting on us to be there.

Supervision of Staff

HHA/RN/LPN follow State/Federal and Agency regulations and best practice initiatives

RN: once per year/LPN :Biannually/CHHA

First case supervision all levels of care

Client is supervised every 30 days

90 Day appraisals/Annual Appraisals of staff

Annual Appraisel

Supervision of Client

Every 30 days

Change in status

Every 56-60 days for ROC (recertification of services)

Post Hospitalization

Discharge

Reassessments: Change in statusFalls/Incidents

Day 56-60 by RN or CSPost Hospitalization

Discharge

Supervisor Check LIst:Assess Patient Vital signs/pain/ Diagnosis pertinent & changes noted

Assess nurse performance/ procedures and treatments and level of skill

Medication Reconciliation/storage/expiration dates

Patient MD appointments/updates

Patient Education/response

Client/Family Satisfaction

Chart/POC in order and organized

Review 485/POC with family/staff

Case conference/Cases management occuring

POC current for Certification period

Goals Addressed/updated

DME organized and Clean

OSHA maintained: hand washing

Safety needs

Discharge Planning

Hospitalization• Notify family if not home.• Notify HHA office/ DOCS.• Notify Client Physician.• Notify Respiratory DME vendors, e.g. trach / vent,

oxygen.• Documentation.• HHA ON CALL SYSTEM (24/7) ________________

911

Performance Improvement

RISK Management

Grievance Logs

Incident Reporting

Accident/Injury reports

Workman's comp

Medication errors

Tracking Occurrences

Medication Errors

Decubiti/skin breakdown

Infections: Wound, Respiratory, Urinary

Client falls

Employee injuries

Track, Investigate,

Evaluate, Analyze, Write a plan of

Correctionto Prevent and

Improve Outcomes

Quality Improvement

All nurses notes are Q/A weekly: read and Signed by DOCS

All Charts are Q/A quarterly: audited for protocols and errors

Errors are reviewed; performance reports are written; Education/Re-education is provided;metrics are reassessed within 30 days and reviewed

Errors and Incidents are learning tools for the future and utilized to improve future processes

Performance Improvement Plan developed/Implemented/ Evaluated 30 days