Home care agency concerns

JustBeachyNurse, LPN · Nov 19, 2014

Are you looking for specifics? Do you have paperwork samples from orientation? Do you have a nurse educator to consult with? Do you follow the plan of care? Do you use flow sheets or straight narrative charting? Are you documenting progress to 485 goals each shift (not just restating such as goal "patient will tolerate enteral feeds via GT without reflux or s/s malnutrition" would be "client tolerated continuous feed at 80mL/hr over 8 hrs. Residuals less than 30mL. No s/a reflux or distress, dehydration or malnutrition No PO intake this shift" instated of progress written as "patient will tolerate enteral feeds via GT without reflux or s/s malnutrition" (copying goal verbatim with future tense verbs. Progress is now not in the future. Goals are in the future )

caliotter3 · Nov 19, 2014

If the agency does not provide you with a form for your shift note, signature by the client for pay purposes, or a medication administration record, and does not respond for your requests for these documents, I would go to another agency for work. As easy as that.

doodlebuttRN · Nov 19, 2014

I know what I am required to chart, the forms and such, according to my agency. I am curious if there is a resource or regulations for PDNS in my state that will tell what we are required by the state, to do. I DO NOT want to get into details, but the situation is pretty much what caliotter said. What happens if the state comes and wants to review the records for a patient but the nurses in the field never received the monthly TAR, various logs' etc.

I really don't want to leave, but like caliotter said, I understand I may have no choice. I am looking for anything that can tell me what the legal issues are here and if I amputtingmyself in jeopardy here.

JustBeachyNurse, LPN · Nov 19, 2014

I know what I am required to chart, the forms and such, according to my agency. I am curious if there is a resource or regulations for PDNS in my state that will tell what we are required by the state, to do. I DO NOT want to get into details, but the situation is pretty much what caliotter said, but this has never happened before, until now (this month). I work for more than one agency, and I am familiar with the basic requirements for documentation, but what happens if the state comes and wants to review the records for a patient but the nurses in the field never received the monthly TAR, various logs' etc. Am I putting myself in jeopardy here? I have my own narrative charting completed every shift without fail.
I really don't want to leave, but like caliotter said, I understand I may have no choice. I am looking for anything that can tell me what the legal issues are here.

Call your BoN. Start there. There may no legal requirements specific to PDN except perhaps in Medicaid requirements.

Essentially you know what documents are needed. It seems "traditional" monthly forms/logs typically provided by the clinical agency (TAR, MAR, care plan, feed logs, narc logs, seizure logs, flow sheets, etc) are not generated and available in a timely fashion...

Assuming you document all care, medications, treatments, assessments, progress to goals etcetera in your narrative (as opposed to using flow sheets & chart by exception) you should be covered until you move on.

I saw an insurance audit recently. The monthly logs were glanced at but the primary documentation used to determine continuation of care were the nursing narratives, time sheets, monthly RN assessment/evaluation logs, and progress to 485 goals. Payment was lost due to incomplete documentation and an appeal was needed to reinstate full hours. The MAR & TAR only had scheduled times whereas the narrative (should have) had specifics including rationale for late or skipped scheduled meds, reason for PRN and appropriate assessment post PRN. It was a nightmare.

caliotter3 · Nov 20, 2014

In the past, I have used generic forms or forms from other employers where I have removed that company logo. The agency I was documenting for accepted the jury-rigged forms and I even got complimented one time. But in each situation, the agency eventually came forward with their version of the form. You can make these forms yourself and turn them in as documentation, but if the agency does not accept them and/or does not give you their proper forms, you are still on the hot seat. Why? Because how do you know that when you turn the nurses' notes in, that the office personnel don't promptly trash them? Recently I was with an agency where each and every time I turned in a physician's supplemental order, for some strange reason, there was never any action. When I queried the office personnel, they had absolutely no idea what I was talking about. When it comes to doctor's orders, you can get around that kind of behavior by sending the order directly to the doctor's office for signature. The doctor will send the signed order back to the agency, and I highly doubt they would be so inclined to dispose of a piece of paper with his/her signature on it. It is sad when we are responsible for our job in the field and the job of the people in the office at the same time.

doodlebuttRN · Nov 20, 2014

Thank you caliotter and JustBeachy. It seems as though the situation has been rectified, for the time being. I really appreciate your input and experience. I will continue to be conscientious with my documentation, and to follow closely on what happens after it is submittec. In home care/ private duty, sometimes there is such a disconnect between the nurses in the home and the nurse managers/ clinical staff at the agency. Having been in home care for a few years after working in hospitals and nursing homes/ SNFs; it still takes some getting use to. I am so grateful for allnurses help me put things in perspective. Thanks so much to everyone.

caliotter3 · Nov 20, 2014

I keep one blank copy of each of the forms for each agency that I work for, for the above reason, as well as having a "master" copy for copying when I run out of forms on a day to day basis and can't get to the office to pick up blank forms. Frankly for a nurses' note, all you need is a form with X number of blank lines. As long as you write the patient identifiers, name and case number, date, and your signature/printed name at the bottom, you are good to go. You can also jury rig a med admin record this way. Work on your part, but usually acceptable. Hope you don't run into any other problems with your agency.

JustBeachyNurse, LPN · Nov 20, 2014

As part of orientation, my second agency actually gives a stock pile of blank MAR, TAR, narrative, seizure and other logs as part of the welcome "kit". My primary agency has started doing the same.

I think some of the nurses eat the narrative paperwork. I always have a week's supply at least of the basic paperwork. More than once I've filled in to find NO paperwork (like how did you not notice that you took the very last copy marked "master" of single page forms or the sticky note on the last copy of the NCR(duplicate copy) forms.) People amaze me sometimes. I've helped reopen a case and no one noticed that the MAR wasn't in home, I was able to manually create MAR/TAR and other logs by using my stash of blanks. The clinical supervisor (who does do follow up on such issues, thank goodness) personally delivered replacement back-up paperwork so that I could be prepared if it happened again.

caliotter3 · Nov 20, 2014

One of my previous clinical supervisors started bringing a stash every time she made her supervisory visits. The forms would be gone the next day. Oh, and don't even talk about the supply of stamped, self addressed envelopes for sending paperwork to the office. Whichever nurse is on duty when those arrive at the home, or when a supervisor brings a stash, takes every single one of them for her/himself. And then on a case, a new nurse to the case has the audacity to have the client ask me when I am going to go to the office and bring blank forms for HER use. I told the client to pass on to her that she can go to the office to get her forms like I go to the office to get my forms. I'm sure that went over fine and dandy.

smartnurse1982 · Nov 20, 2014

In the past, I have used generic forms or forms from other employers where I have removed that company logo. The agency I was documenting for accepted the jury-rigged forms and I even got complimented one time. But in each situation, the agency eventually came forward with their version of the form. You can make these forms yourself and turn them in as documentation, but if the agency does not accept them and/or does not give you their proper forms, you are still on the hot seat. Why? Because how do you know that when you turn the nurses' notes in, that the office personnel don't promptly trash them? Recently I was with an agency where each and every time I turned in a physician's supplemental order, for some strange reason, there was never any action. When I queried the office personnel, they had absolutely no idea what I was talking about. When it comes to doctor's orders, you can get around that kind of behavior by sending the order directly to the doctor's office for signature. The doctor will send the signed order back to the agency, and I highly doubt they would be so inclined to dispose of a piece of paper with his/her signature on it. It is sad when we are responsible for our job in the field and the job of the people in the office at the same time.

I just tell the Doctor's office to fax orders over to the agency and i will usually give them the agency's fax number.

I also write an order for it on the Physicians order form as an FYI to the other nurses.

The worst is when a pt goes to the hospital and most of the orders change...that is a big pain in the you know what.

According to Agency A any orders that are written on discharge orders,you do not have to write them again on the Physician's order forms.

Agency B says you have to write them.