How do I propose a change in Home Health in NJ...

[hoolahan, ASN, RN]

OK. We were all having this discussion in the office yesterday. WHY can't a LPN do Home Health Aide (HHA) supervision visits? I am not talking about PCA's under Medicaid or various other programs. (I mention these b/c visits are made much less often, and it wouldn't pay to have a LPN when the RN must do the assessments.)

But seriously. In LTC, even in NJ if I am not mistaken, LPN's can be in charge of a unit, even sometimes over the RN, so why on earth can't they do HHA sups?? Clearly in this setting they are supervising CNA's, right?

It can be a problem when we have several per diem LPN's who need assignments, and I have too many visits, but I can't give up my HHA sup visits. Sometimes these are for PT only cases, and no nurse is really needed except to sup the HHA. It is irritating, b/c then I have to give my unstable cardiac visit up (and cardiac is my forte) b/c technically, a LPN can visit. It makes no sense. I would much rather follow up on a more critical pt (not saying at all that our LPN's aren'y perfectly capable, please don't get me wrong.) It is so annoying not to be able to follow through on things, and remember I have to follow up with any verbal orders based on the LPN's report (another stupid rule) all so I can see a non-critical pt to see that their HHA is giving them a good bath!!! That is the visit I want to give to a per diem! But we don't have enough RN per diems.

So, I want to petition the NJ State BON to make a change in these two laws, 1. Allow LPN's (with proper training/education -like we ever got any) to sup HHA's and 2. Allow LPN's to take verbal orders in homecare. (I don't mention hospitals as most have an RN there who, even if inconvenient, can do it.)

How do I start? Whom should I get involved? Should it just be a petition? Should I request nurses write to a certain political person (which one-senator, congressman, I am so politically ignorant??) What is the correct and best way to achieve this, and how fast do you think we could accomplish change?

Thanks to all for the expert advice I am sure I will receive.

[NRSKarenRN, BSN, RN]

It is a MEDICARE so therefore MEDICAID rule that only RN's supervise HHA's. In order to get paid, need to follow the rules for these insurances----all other insurances follow MC guidelines.

Since most state programs come from these funding sources, that's who you need to petition.

Remember, LPN's are dependent practionioners working under the agencies Nursing Supervisor AND YOUR LICENSE per state BON regulations.

I agree that most LPN's certainly are capable after a year of practice and do so in long term care. But also realize the fraility of most elderly who sush substandard care in fear of not getting ANY care.

A change like this is monumental.

RE verbal orders-that is a STATE requirement. PA has taken FIVE YEARS to review and consider impact of change. We might see it pass this year.

[hoolahan, ASN, RN]

How do the LTC facilities get around that issue? Is RN supervision of CNA's not a requirement for their care and caid reimbursement?

OK, as far as LPN's working under my license, they are already doing that, so I am not worried about that issue. They are instructing pt's about new meds etc in my absence and that is more critical IMHO than a HHA sup.

I am also not concerned about the most frail being afraid to speak out. If they are afriad, they are afraid no matter who is doing the supervising. I have experienced what you are talking about. One pt told an RN who was leaving the agency that her HHA was sleeping, but she made her swear that she would not tell the new CM, me. But, she did tell me, yet I am not supposed to know. What, am I supposed to just show up one day and catch the aide sleeping?? I have tried, but she seems to know I am there. SO, if the pt won't tell me, and I am not supposed to know, I can't do one thing about it! (Well, I can, the sub was great and I suggested she b/c the regular aide, and the assignment was switched.) But, the fact remains, it doesn't matter if you are a secretary, if the folks don't "want to get their aide in trouble" they won't tell. If they do, it is a person they trust regardless of their title.

Those two arguments aside. it has to beign somewhere.

Karen, are you saying it would have to be a national petition since it is hcfa? All of NJ wouldn't count since the rules are the same everywhere, nationwide, right?

Where you you begin such a task? I want to pursue it, no matter how much work it involves. Should I try to get backing from more big wigs first? How and who?

With the current state of RN shortage in my agency, I could spend my whole week doing just HHA sups!!! I didn't return to case management to do that!

[-jt]

Id start by asking the NJ State Nurses Assoc and the National Federation of LPNs (NFLPN) and the home care nurses association chapters in NJ. Between them all, somebody is bound to be able to direct you, have some suggestions, explanations or ideas

[Jenny P]

Hoolihan, first read your Nurse Practice Act for definitions on what the LPN and the RN scopes of practice are. Here in Mn, "the practice of practical nursing" covers such things as "observing and caring for the ill, injured, or infirm, in applying counsel and procedure to safeguard life and health, in administering medication and treatment prescribed by a licensed health professional,..., but which do not require the specialized education, knowledge, and skill of a registered nurse."

Supervision is not in an LPN's scope of practice according to Minnesotas' Nurse Practice Act. New Jersey probably has very similar wording in its' Nurse Practice Act. That being said, I can't help but wonder 2 things: how do LTC facilities have LPNs "supervising"; and maybe what you do when you "supervise" the HHA isn't really "supervising" in this instance. It sounds very much like "observing" to me. According to my Oxford English Dictionary, to "observe" is to "1. to see and notice, to watch carefully. 2. to pay attention to (rules, etc.) 3.to keep or celebrate. 4. to remark 5. to make scientific observations." Whereas, to "supervise" is "to direct and inspect (work or workers or the operation of an organization." So the question is, are you observing or supervising the HHA?

Changing the whole scope of practice for LPNs and RNs may be much harder than changing WHAT IT IS that supervising the HHA involves.

Just a suggestion.....

[hoolahan, ASN, RN]

Jenny, you make an interesting point. The HHA;s have their own supervisor who does their eval's etc. BUt according to hcfa regs, a HHA must be "supervised" q2wks in actute care cases, q60 days in Medicaid PCA program. Even if they hired a FT RN just to do HHA sup's, she would still not be able to fit them all in a week, our agency is pretty big.

jt, great ideas, I will look into it and post when I hear any replies.