Bottom Line

caliotter3 · May 20, 2012

The diet should be written on the 485 which is signed by the doctor. I have given such a concoction as you described and the 485 said that the patient was to receive a regular pureed diet. Mom cooked regular food and pureed it. All I had to do was to remove it from the frig and heat it up. Private duty does not require that you see any doctor's orders, the 485, prepared and used by an agency. You are not an agency employee. However, if the mother were using her head, she would let you see the plan of care prepared by the agency, so you would feel comfortable with the instructions given to you. After all, you would be following the 485 once you are "turned over to the agency", as you put it in your other thread.

Anything that you do based upon verbal instructions from the mother is to be charted, "as requested by Mother", or "per instructions of PCG", or similar verbiage. That is how I have always been told to handle these situations. If you do NOT want to do something that the Mother tells you, then you request that she do it herself and you chart that she did it (because you witnessed her doing it and you want that to be charted). For example, "Mother administered approximately 10 ml of a light pink liquid per GT. Pt. tolerated well." Remember, if you don't feel comfortable, whether private duty or through an agency, then do not accept the assignment. The mother has laid out the parameters of the job, it is up to you to decide whether or not, they are acceptable to you.

tothepointeLVN, LVN · May 24, 2012

In practice the 485's are often months out of date even if they have been recently renewed. At one of my cases a supervisor didn't come out for 6 months so they have just repeated everything that was on there. So what ever it is that she's asking to do call the office and have the 485 changed. They'll do it.

Also don't come into a hospice shift and get into a tizzy with the other nurse and call the supervisor because there is no 485 and not listen to reason about how 485 is not an applicable document to case. Just saying I've had that happen.

kdavispn · Jul 15, 2012

You are REQUIRED to see that 485 and MAR. Period. Legally if the certification period is not current, you do not have orders to be there at all.

Moms schedule is great, and you can use it, if it matches the MAR, and 485. Moms change the orders all the time, but legally you are liable if you follow them and something happens to that patient.

For example MD wrote orders for Tylenol for fever. Mom tells you to give Motrin. Baby has a reaction to Motrin, goes to the ER. You're in trouble not matter what mom says, and mom might just say you pulled the Motrin out your purse and she told you to give Tylenol. If if the Motrin worked with NARN, you still made an error that you'd have to explain.

Sometimes the Dr. writes an order that states " give xyz and the discretion of the pcg" the pcg may tweak those orders only, and even then you use nursing judgement, safe practice, and documentation to protect the patient and yourself.

allnurses Guide · Jul 15, 2012

I believe the 485 that is generated by the agency you are not employed by is not considered a legal order for you working in an independent capacity. I looked this up on the BVNPT site several months ago. The patient's doctor needs to write a separate set of orders for you to legally carry out.

tothepointeLVN, LVN · Jul 15, 2012

You are REQUIRED to see that 485 and MAR. Period. Legally if the certification period is not current, you do not have orders to be there at all.

The background on this question was the OP was being paid by the mother directly a true private duty nurse. The 485 is a documentation when nursing services are being paid for medicare or medicaid . Its a certification document so the agency can prove the standard of care is being provided etc and so they can get reimbursement for services provided. No third party payer = no 485. Also its for home health services not hospice or any other kind of service.

But primarily its all about getting paid. If your not being directly or indirectly being paid by medicare/medicaid/insurance then your not REQUIRED to see the 485. It's nice to see but it's not a right you have.

tothepointeLVN, LVN · Jul 15, 2012

I believe the 485 that is generated by the agency you are not employed by is not considered a legal order for you working in an independent capacity. I looked this up on the BVNPT site several months ago. The patient's doctor needs to write a separate set of orders for you to legally carry out.

This is what I meant to say but was less eloquent about it. Even if you are working for an agency they have a sneaky habit of re-certifying the case but never updating the information so the certification period is current but everything else is wackado though time and typos. I don't work private duty any more so don't have to deal with it but occasionally in my travels as mentioned above I'll come across a PDN who recently switched over to hospice making a woopdedo about needing a 485 which is not the appropriate document to have so them asking for it gives them away LOL

allnurses Guide · Jul 15, 2012

this is what i meant to say but was less eloquent about it. even if you are working for an agency they have a sneaky habit of re-certifying the case but never updating the information so the certification period is current but everything else is wackado though time and typos. i don't work private duty any more so don't have to deal with it but occasionally in my travels as mentioned above i'll come across a pdn who recently switched over to hospice making a woopdedo about needing a 485 which is not the appropriate document to have so them asking for it gives them away lol

and i just discovered that "several months ago" post was about this same case, which has been revived. anyway, here is where i found the information if anyone is interested: http://www.bvnpt.ca.gov/pdf/brochure5.pdf

[color=#2f4f4f]6. remember that the lvn or pt must

[color=#2f4f4f]receive client care orders from your

[color=#2f4f4f]physician.

it would probably be the same as what is on the 485, but that document is solely between the client, the doctor, the agency and the state or entity who is paying for the skilled nursing care.

tothepointeLVN, LVN · Jul 15, 2012

Yeah in the case of true private duty you can get the doctor to fax over a set of orders and that within reason should cover you. I know theres a few people that haunt this section that have done true private pay private duty and they know the P&Ps better than I.

But the right form for the right job.

caliotter3 · Jul 15, 2012

Private duty clients rarely take the private duty nurse to doctor appointments. If the nurse does not trust the client to provide an accurate rendition of the doctor's orders, then that person should attempt to contact the doctor or not accept the case. The 485 is provided by the agency that handles a particular case for those employees who are employed by that agency. Since this document is signed by the doctor, it would be in the client's best interest to allow a private duty nurse to see the document, as I stated in a prior post.

allnurses Guide · Jul 15, 2012

Private duty clients rarely take the private duty nurse to doctor appointments. If the nurse does not trust the client to provide an accurate rendition of the doctor's orders, then that person should attempt to contact the doctor or not accept the case. The 485 is provided by the agency that handles a particular case for those employees who are employed by that agency. Since this document is signed by the doctor, it would be in the client's best interest to allow a private duty nurse to see the document, as I stated in a prior post.

The document is signed by the doctor, but the document is generated by an employee of the agency, so if the client chooses to let the non-agency nurse see the chart, it would only be for educational purposes, not a legal order, since that permission can be rescinded by the parent/family at any time. It was my understanding based on the brochure from the state of CA I linked to, that a private duty nurse must work under physician's orders, and not what the parent or client communicates to the nurse those orders to be. Going with the person to the doctor wouldn't be necessary.

I don't think I would be comfortable under those circumstances, as unreliable and forgetful as some people are. Not always intentionally, but it couldn't be ruled out with some people and/or their family members.

So if someone isn't seeking Medicare/Medi-Cal payment, thus no contracting agency or 485 to look at, an independent private duty nurse follows the directives of the client? I didn't know that. I'm wondering how you would get around that "LPN/VNs work under the direction of a physician or RN" part of the Scope of Practice?

You mentioned charting in your prior post - where are you charting? You can't chart on the agency's home chart if you aren't their employee - you can write in a spiral notebook, but the agency-employees have no obligation to read it or be held liable for actions they did or didn't take based on what is written there. I've never taken a non-agency job, so I'm asking for future reference. Thanks in advance. :) (sorry for length of post)

caliotter3 · Jul 16, 2012

Some private duty clients ask that private duty nurses write shift summaries in a spiral notebook for day to day reference. When working private duty, I will not go out of my way to provide written notes unless the client requests them.