Orientation to Homecare 101 Home Care Series by Tammy Marie Baker RN
Home Care vs Facility Care The Arena Changes The Arena ChangesHome Care Facility Care Bathroom Dirty Utility room Kitchen Clean utility room CSR: Central Supply Room DME: Durable Medical 24 hour in house pharmacy Equipment Code Team/ ICU Elevators Local pharmacy In house therapist ( PT/OT/Speech & gym) 911/you/ambulance Whole Nursing Team IV Team Steps Respiratory Therapy Team 24/7 Visiting therapists Home Health Nurse
The Home Care Nurse Nurse Case Supply Manager AcquisitionTransportation coordinationAppointments Bathing, ADL, Personal & School Care Nutritional Needs
Home Health Care ArenaAdvocacy Physician Home School TravelNursing Am care Feeds Wound care Medications GT/ oral TUBE CARECare ADL/ OOB Ostomy /Foley Transfers administration Clean Supplies andSupplies Physician orders for Procurement Acquisitions Equipment everything Administer Reorder/ restock Call MD for reorders Call Pharmacy asMedication Reconcile Pharmacy Pick up needed. Pick up meds PRN Communication Letters of medical Schedule Relay for the family Verbal Orders necessity appointmentsPhysician and MD Written transcribed and Prescriptions Arrange signed off. Transport
Physician OrderHome Care Physician orders are the signed 485 POC485 is signed by DOCS and MD485 POC is updated / re certified every 60 daysAll treatments and Medications must have a physician orderSupplies require MD Prescription for ReimbursementSupplies may also require a letter of medical necessity with RxThe homecare Nurse is instrumental in helping the family get supplies throughcommunicating with the PhysicianThe 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.
485 “ THE PLAN OF CARE”THE 485 IS “THE PLAN OF CARE”IT IS THE PHYSICIANS ORDERS FOR THE HOME CARE CLIENTIT DESIGNATES: DIAGNOSIS CODES; ASSESSMENT PARAMETERS; TREATMENTS;MEDICATIONS ; DME EQUIPMENT; ALL WRITTEN ORDERSIT 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 POSTASSESSMENTA VSOC IS OBTAINED AFTER MD IS GIVEN UPDATES/SPOKEN TOIT MUST BE IN THE CLIENTS HOME CHART and CURRENT DATES EVIDENT FOR STATECOMPLIANCE
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 hoursby 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 POCby 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, andCompliance.Call your DOCS with “ ALL NEW ORDERS”.Original orders come back to the office with Nurses’ notesYellow back up stays on the home chart. The home Chart and the Office Chart should both have the same andcurrent information and orders.
485 The Nurses Responsibilities READ IT~ LEARN IT~ FOLLOW IT READ IT~ LEARN IT~ FOLLOW ITThe Nurse or HHA is responsible for knowingtheir clients POCThe nurse should document according to thegoals and treatments on the POCEducation is geared to Goals and POCorientedGoals are reviewed and revised and accurateto 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 yourFull legal signature & Nursing credentials.Sign those initials. You earned them. Be proud of them- LPN/RN/CHHADocumentation 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
PDN FLOW SHEETTime in___time out____: circle( AM/PM) the time you started and check date by calendarDocument full Vital Signs at least once per shift and per MD ordersCheck all appropriate boxes per system.Pain is the 5th vital sign document itEducation: Related to goals /Diagnosis/Medications/discharge planningCalled MD? document call/time and whyNarrative summation of Shift. Subjective ( factual events and patients tolerance ofcare/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 proactivenotes are written on shift not before or after
Intake/Output Spinal Fluid Cerebral Record all Fluids/Solids/Nutrition/Excretions/secretions Entering/Leaving the body Blood/BileIntake: anything that enters the body Mucus/Saliva Anything that leaves the body Output: Emesis/Vomit Oral solids or liquids Chest Tube Formulas Intravenous GT residuals Parental Nutrition Flushes Purulent drainage Irrigations Enemas Wound drainage Wound Vacuums Hemovac/ Jackson Pratt +/= Add up all Intake and output at end of shift Urine/Urostomy
Documentation “ no/no” list “ 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 X X error strode k
MEDICATION RECONCILIATION Patients medications are reviewed daily by PDNMedications must have 5 rights :1-Right patient ( whose prescription is it?) IDENTIFY THE PATIENT2-Drug Name3-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 DOCS Medication profile and Mars must be accurate and reflect all current meds ALL MEDS ARE SIGNED OFF ON MARS FULL SIGNATURE AND INITIALS AT BOTTOM OF MARS MEDS NOT GIVEN? CIRCLE YOUR INITIALS AND DOCUMENT WHY Med 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 ORDERS what the skilled nurse should know? what the skilled nurse should know?HOW TO WRITE A MEDICATION ORDERPROPER FORMAT (CONCENTRATION) HOW MANY ( __MG/___ML ) we must have this on everymedicationDO NOT USE “CC”DOSAGE ORDERED : HOW MUCHFREQUENCY /DURATIONPRN 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 CHARTINGMED PROFILE ON EACH CHART FROM ADMISSION, UPDATED PRN AND AT RE -CERTIFICATIONS;SIGNED BY NURSE AT SUPERVISIONS EVERY 30 DAYS; NEW PROFILES NEEDED WHEN MEDSCHANGEADMISSION MED PROFILE REQUIRES DATES OFF PRESCRIPTION BOTTLES NOT DATE OFADMISSIONMED PROFILE REQUIRES MED CLASSIFICATIONS FOR EACH MEDMED PROFILE SIGNED OFF DAILY BY RN INITIALS IN BOXES ONLY IF GIVENDO 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 MARSNURSE MUST DATE/TIME/INITIAL IN BOX FOR EACH MED GIVERECONCILIATION SIGN THE MEDS MATCH THE MD ORDERS WHEN NEW MARS RECEIVEDMED 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
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 Diversity RESPECT~UNDERSTANDING ~ EDUCATION RESPECT~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; clothinghand shaking etc ACCEPT~UNDERSTAND~REACH OUT
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 ofsmall 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 coversStove handle covers, pot handles inwardMedicine safety lids and out of reachPoison control hot line # presentBed rails or crib rails, gates upTub safety, never leave unattendedWater 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 CleaningAll 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 StaffHHA/RN/LPN follow State/Federal and Agencyregulations and best practice initiativesRN: once per year/LPN :Biannually/CHHAFirst case supervision all levels of careClient is supervised every 30 days90 Day appraisals/Annual Appraisals of staffAnnual Appraisel
Supervision of ClientEvery 30 days Reassessments:Change in status Change in status Falls/Incidents Day 56-60 by RN or CSEvery 56-60 days for Post Hospitalization DischargeROC (recertification ofservices)Post HospitalizationDischarge
Supervisor Check LIst:Assess Patient Vitalsigns/pain/ Diagnosis Chart/POC in order and organizedpertinent & changes noted Review 485/POC with family/staffAssess nurse performance/procedures and treatments Case conference/Cases managementand level of skill occuringMedication POC current for Certification periodReconciliation/storage/expiration dates Goals Addressed/updatedPatient MD DME organized and Cleanappointments/updates OSHA maintained: hand washingPatient Education/response Safety needsClient/Family Satisfaction 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
Tracking OccurrencesMedication ErrorsDecubiti/skin breakdownInfections: Wound,Respiratory, Urinary Track, Investigate,Client falls Evaluate, Analyze,Employee injuries Write a plan of Correction to Prevent and Improve Outcomes
Quality ImprovementAll nurses notes are Q/A weekly: read and Signed by DOCSAll Charts are Q/A quarterly: audited for protocols and errorsErrors are reviewed; performance reports are written; Education/Re-education isprovided;metrics are reassessed within 30 days and reviewedErrors and Incidents are learning tools for the future and utilized to improvefuture processesPerformance Improvement Plan developed/Implemented/ Evaluated 30 days