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HH visits at ALF

Home Health   (5,943 Views | 20 Replies)

anticoagulationurse has 7 years experience .

8,416 Profile Views; 417 Posts

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KateRN1 has 20 years experience and specializes in COS-C, Risk Management.

1,191 Posts; 14,368 Profile Views

I used to do HH in rural Southwest MO. I feel your pain, I really, really do.

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spejsa specializes in Cardiac.

153 Posts; 4,206 Profile Views

The problem is... My hubby doesn't understand but nursing really SUCKS here. There are 4 hospitals and 2 are owned by one corporation, so not much to change to in the hospital setting... Only 2 other HH agencies in the area so if I leave and go to another I only have one left. In 4 years I have already burned all my bridges hospital wise in this area. My boss at the agency I am leaving said she will be my reference and has heard great things about me. Thinks I am a great nurse!!! Then, why can I not find a good fit?

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RubyRN,CHPN has 15 years experience.

172 Posts; 4,323 Profile Views

Hi, I live in Washington and feel your pain. I have some important information from my experience as a home health nurse visiting residents of ALF's. Should you have more specific questions, please review WACs for ALF in WA.

Questions:

1) Do you think the ALF is trying to get outside nurses to care for the wound so that there is no real record of the wound on their forms? Thereby avoiding penalties on whatever reports they have to provide to Medicare?

No I don't believe this is always the case. I think of Home Health Care Services as an entitlement for medicare beneficiaries who qualify. Medicare does not pay for beds in ALF; usually, it is private pay, state pay (medicaid) or third party (LTC insurance.) Having a nurse from a medicare certified HH services in does not constitute duplication of services; it enhances the services the resident recieves and benefits your patients at ALF. For medicaid pt's., I understand that it is customary for ALF licensed nurses to provide pt's. with simple dressing changes as having medicaid pay for home health services in this case would constitute duplication of services. As far as no documentation of wound thier forms, I would think it poor documentation on their part and not yours. Somehow the physician has been informed their resident has a wound and has ordered services because maybe it is not something they are staffed to perform. Keep in mind, ALF is primarily staffed with CNA's who have taken fundamentals of care and nurse deligation classes. If a simple dressing change is to be deligated to the ALF staff, it is not your responsibility to deligate, their nurse deligator or RN consultant should be doing that. It is your responsibility to have discussion with her about what the physician has ordered and who will be doing what, how often and blending your plan of care with her, providing her with a copy of your physician order and POC if that is in your agency policy. If the pt's. have wounds due to observable neglect, please do the right thing and report.

2) Do you think they just order HH because the staff nurses "don't have time" to deal with the wound which they caused due to their negelct?

No. Complex wounds are usually outside of type of care their licensed nurses can provide within the services of ALF care. They are drawing on your agency's expertise to assist the pt. with wound healing. Some time ago WACs for WA spelled out how many pressure sores at what stages ALF residents could have to reman in ALF. Most ALF desire their patients to age in place. They want their residents to stay. If you think the wounds are caused by neglect, take the worry off yourself to investigate and report it to the proper authorities.

3) Is this habit reportable? To whom?

Your immediate supervisor, physician, and DOH and whoever else per your agency policy.

4) Should our HH agency even accept these cases from this referral source?

I think that is a matter left up to your administration. Think about what is fair to the patients.

5) Am I held liable even though I attempt to decline the referral and document honestly, but am asked by supervisors to change it?

A while ago attended a risk management webinar on appropriate discharges. Remember, many people in ALF and their families are depending on you as a vital team member in the their care. I believe you must make an honest attempt to evaluate the pt's. needs and to determine if they are appropriate for homecare and meet admission criteria including having appropriate caregivers in place to assist the pt. in meeting goals. If pt. does not meet your agency admission crieteria it is important you assist them in transitioning to appropriate level of care such as wound care clinic. You are more at risk, I would believe for not accepting the referral if you are not following your agency's admission policy/protocal.

I suspect this topic fully deserves more discussion as I find it is often unclear who is responsible for what and how to bridge/blend plans of care in ALFs. Very challenging subject. Sometimes very difficult for home health nurses to fully understand.

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anticoagulationurse has 7 years experience.

417 Posts; 8,416 Profile Views

Immensely helpful! Thanks everyone! I guess I have been looking at it the wrong way.

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138 Posts; 3,233 Profile Views

I have a similar situation... I received a referral from my office for the following:

A woman who was recently discharged from the hospital with a DX of possible cholecystitis. The MD wants labs (CBC, CMP, Amylase, Lipase) drawn prior to appt this Friday. She lives in an ALF and teh family says "all of her needs are met there. We don't think she needs a nurse on an ongoing basis." But, the office when I asked about it says we can't just go out for a blood draw but she is 80 and "Surely you can find reasons to go out". I went to see her and she has Alzheimers'. The staff was all in a meeting when I was there so I was not able to ask any questions about anything else and don't know what else I can do with her... I have been to this place in teh past and the staff did not want to be trained or taught anything. They are busy doing their jobs, etc... The LPN I work with told the agency that she went there in the past and did teaching, blah blah... I don't see a need for us to bill and really think the dr just sent us to do labs.. I could make something up but really... Should we just go out to chat with the pt and waste their time? Do we expect that the staff will learn? What to dO? I didn't get the blood draw so I will have to go back to get it so I guess I will find something I have to teach...

The ALF I have worked with has a lab that comes there upon doctor's orders to do lab draws and send them to the lab for analysis. Home health care nurses will not be paid for venipuncture only, and if her family is discouraging any additional outside intervention, I can't imagine what you would be able to do there,either!

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DMCRN specializes in Operating Room.

18 Posts; 1,588 Profile Views

I have worked for an ALF and in order for a patient to qualify to stay in assisted living they have to be "chronic and stable". And yes nurses in ALF are qualified to do skilled nursing care, however it is the facility that requires them to refer to a HH agency for a "skilled" wound...not just a skin tear cleansed with NS and covered with bacitracin and telfa. Also these patients are private pay...in the place I worked they paid around $6k a month in fees to live there. The ALF cannot bill Medicare for a skilled nursing tx, so you are incorrect when you say that Medicare is paying the ALF. You won't see many pressure ulcers at any decent ALF so I can't speak on that facilities behalf...

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Finestnurse, Lpn has 8 years experience and specializes in ALF.

14 Posts; 632 Profile Views

By law, at least in Ohio, this is a state regulation! The law states that wounds not expected to heal within 180 days are to be monitored by an outside agency. As a nurse with 8 years experience in AL, we use home health all the time. And FYI, AL is PRIVATE PAY! Medicare does NOT pay for AL! So they are not being taken advantage of twice! Home health is used also for PT, OT and ST along with nursing services if needed. My Director of Health Services (DON) determines when HH is necessary and coordinates with the agencies she feels does appropriate care. She is EXTREMELY SELECTIVE on whom she allows in our facility. Nothing but the best for our residents.

We also have 50+ residents to one LPN and 2 caregivers for AM shift than 100 residents to one LPN and 2 caregivers for PM shift. Having outside agencies such as Home Health and Hospice services helps us keep up with our heavy ratio of staffing. These residents are not healthy either (majority). Maybe 15 of the 100 do their own medications. They have ambulatory, memory, toileting issues not to mention all the parkinsons and chf folks.

And 9/10 wounds from my facility are ones that residents moved in with usually from the hospital, skilled facilities or home care. My facility provides excellent care with what is given to us.

We have been 7 years citation free from annual state surveys!

I know this post is old but i really would like the perception of working at an Assisted Living Facility to not be considered an "easy job." I work my butt off just like every other nurse. I see ALL THE TIME that misconceived notion that its easy work because the people "arent that sick or just need companionship." THIS is by far not true. I see caregivers hire in and work one day than say :this isnt what i thought it was going to be" than they never come back. 8 years ago when i started AL things were quite a bit easier but as the years drag on it gets tougher and tougher with no additional staffing. Our administrator said THIS is the way AL is these days. People just cant afford to go into an AL when they are healthier so families keep them home longer until they just cant do it anymore.

I work 12 to 16 hours a day usually skipping an unpaid lunch and sometimes not using the restroom the entire day! Dont be so quick to judge! We work hard too!

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Not_A_Hat_Person has 10 years experience as a RN and specializes in Geriatrics, Home Health.

1 Follower; 2,900 Posts; 37,998 Profile Views

When I worked in Assisted Living, the VNA handled hospice cases. The ALF nurses gave meds and the caregivers did some care, but the VNA nurses got orders, managed equipment, and did post-mortem care. The facility really wasn't set up to handle dying residents. The local VNA does hospice and palliative care in local ALFs, even those with nurses on staff, for the same reason.

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137 Posts; 6,698 Profile Views

It seems your thoughts match mine precisely. I think a lot of issues is most ALFs staff med techs, not nurses to pass meds. There are LVNs in most facility but I find the LVNs are mainly in administrative and marketing positions.

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