Going to Patient's home without patient consent - page 2

I work in home care. Normally a physician will send our company a referral for home care. We contact the patient, ask to go to their home for the initial Start-of-Care visit, then start services at... Read More

  1. by   smartnurse1982
    I appreciate this thread. I am new to homecare and i work in Camden,Nj.

    95% of the patients we get referals for do not pick up the phone.
    For that reason,I just stopped by the home most times. I have never had someone refuse for me to see them.
    They were actually VERY grateful for it.
  2. by   JKL33
    Quote from NRSKarenRN
    Home Health agency is obligated to provide evaluation visit once homecare referral is accepted. For Medicare certified agencies, Medicare requires initial homecare eval within 48hrs of ordered start of care date to determine if patient meets homecare criteria especially homebound status and admission to homecare. Well check IS required with outcome documented along with notifying referral source inablity to reach patient.
    Hi, Karen -

    I realize it's been a few months since you posted on this, but now that the topic's been bumped it caught my attention just as a safety issue.

    I see (on official govt websites) where agencies are obligated to provide an evaluation if they accept the referral, and that they must do it in a timely manner.

    I can't find where, specifically, they are required to send someone to the home of a patient who doesn't respond to contact attempts (i.e do a "well check"). Is that in black and white somewhere, or is it an interpretation of agencies who want to make sure that to the best of their ability they are meeting the HH COPs?

    It seems to diverge from usual wisdom. Why wouldn't contacting the police for a well-check meet any such requirement? I certainly don't mean to question you, personally, as someone with a lot of experience and expertise, here - - but it does strike me that the issue of "getting the business" (being able to bill a client) could easily come into play here. By that I mean that there is at least some incentive (separate from CMS regulations) to send a nurse to someone's home to hopefully set up care.

    The "well-visit" strikes me as a potential safety issue, not a HIPAA issue. I think it is problematic if nurses are expected to go on excursions alone to private property where they may not be wanted, or, should I say, where no one can presently confirm that the patient actually intends to participate.
    Last edit by JKL33 on Aug 11
  3. by   Glycerine82
    I will tell you that this was my dad. He would blow off his home health nurses but he really needed to be checked on. He would have let them in had they knocked at the door, but he wasn't a phone kind of guy. He had stage IV head and neck cancer.
  4. by   Libby1987
    Those of you who are wrong, and there are some posters in this thread who are very wrong, are giving out incorrect information and that's pretty reckless..

    The agency has already received the PHI from the referral source with an MD order who had received consent to share this information.

    Driving out to a patient's residence when phone contact wasn't able to be made is not a HIPAA violation. What is it is due diligence to attempt to provide medically necessary MD ordered services to an at risk population in an alternate healthcare setting.

    A welfare check is not a HIPAA violation, whether done by the home health staff or law enforcement. It is an appropriate measure for someone who may be lying on the floor.

    Look up a news story in California where the caregiver was eventually found on the floor after having been dead for 2-3 weeks and bedfast patient dead for a few days, it took that long for the patient to die after his caregiver dropped dead. Patient was already on service but makes no difference related to HIPAA.

    We have sent a number of patients back to the ED where they have been treated and/or admitted, found by SOC clinician after unable to reach patient or emergency contact by phone.

    Not every patient can get to their phone, not everyone can hear their phone, not everyone has a working number following missing a payment after a lengthy stay..

    Consent is needed prior to providing treatment. Permission to knock on a door is not. Patient can decline services at that time.

    And who said something about profits? It costs money in hourly wages and lost productivity to check on a referred patient but it's the right thing to do.
    Last edit by Libby1987 on Aug 14
  5. by   JKL33
    Libby, care to answer what was a sincere question, or just rant?

    I have no idea if you're referring to me with your "profits" statement, but my inquiry arose from a previous poster's statement that if a patient doesn't answer the door a card is left on the door (combined with the context of the rest of the discussion).

    I don't have a problem with knocking or with leaving a card, but it most certainly is not a "welfare check" to leave one's business info on the doorknob and walk away if the patient don't answer. It may be an attempt to meet regulatory guidelines, it may be a business move. But it is not a welfare check if verifying the patient's well-being is not part of the process.
  6. by   caliotter3
    Come to my home without my invitation or my knowledge beforehand and you are going to be informed that you have invaded my privacy. "Referral" or not, somebody gave out my information without my permission. Since we are talking medical basis here, why wouldn't I figure out a HIPAA violation has occurred? So, why are home caregivers admonished not to inform their families where they are going if "patient" locations are not considered HIPAA relevant? Rubbish on the safety claim.
  7. by   Libby1987
    Quote from JKL33
    Libby, care to answer what was a sincere question, or just rant?

    I have no idea if you're referring to me with your "profits" statement, but my inquiry arose from a previous poster's statement that if a patient doesn't answer the door a card is left on the door (combined with the context of the rest of the discussion).

    I don't have a problem with knocking or with leaving a card, but it most certainly is not a "welfare check" to leave one's business info on the doorknob and walk away if the patient don't answer. It may be an attempt to meet regulatory guidelines, it may be a business move. But it is not a welfare check if verifying the patient's well-being is not part of the process.
    Leaving a card in of itself is definitely not a welfare check but the visit to the house of an at risk patient with no emergency contact and not answering the phone themselves after agreeing to home health at hosptial discharge is most definitely with the patient's welfare in mind.

    Every one of our hospital and community referrals involved patient or DPOA agreeing to home health, either directly with one of our liaisons, a case manager and/or the MD/NPP. It's documented in the record to which we have access as part of our system.

    Not infrequently we receive a request by the provider's office to check on a patient they haven't been able to reach, knowing their history and out of concern for their welfare.

    The patients most likely to receive a knock on the door are the ones most at risk, the medically fragile, without a network of support.

    This would be considered by caliotter as an invasion of her privacy and the safety bit nothing but rubbish. Calliotter also doesn't seem to understand, though I know she does, the difference between the home health provider having patients' PHI and sharing it with their own personal family members.

    Now if you work for a company who processes unsolicited referrals then you have a point but I took it at face value that the discussion is around legitimately ordered healthcare.

    I'll say it again, including details you may not realize exist, going to the door at the address provided by verbal agreement documented in the record, as part of the patient's follow up and healthcare plan and ordered by the MD, is not a HIPAA violation.
  8. by   JKL33
    Yes. Not HIPAA.

    I would agree it is in patients' best interest as a well-check as long as it is followed through immediately (police referral) when contact can't be made.

    As far as PCP offices (or HHAs themselves) sending HH nurses to a patient's home for "well check" - I just don't know what to make of that. It's one of those things that (with regard to nurse/worker safety) is all good right up until it isn't, which is the same point it's too late to do anything about that fact.
  9. by   Libby1987
    Quote from JKL33
    Yes. Not HIPAA.

    I would agree it is in patients' best interest as a well-check as long as it is followed through immediately (police referral) when contact can't be made.

    As far as PCP offices (or HHAs themselves) sending HH nurses to a patient's home for "well check" - I just don't know what to make of that. It's one of those things that (with regard to nurse/worker safety) is all good right up until it isn't, which is the same point it's too late to do anything about that fact.
    Except that we do catch some time, either to prevent or to send to the hospital to stabilize. If you've been stuck in a chair whether for 24 or 48 hrs, you'd probably accept rescue at either point in time.

    We have a 48 hr window to see a patient, I'm not speaking to some random several weeks since last seen.

    A few weeks ago I found one dead in the bed. Not because we delayed, I went there within 6 hrs of receiving the referral because a concern was voiced by the hospital after discharged patient didn't answer the phone and we couldn't schedule a nurse to do the SOC until the next morning. Was it futile that I went and should I just give up the practice going forward based on influence by comments in this thread, not only discouraging but some, not yours, claiming a HIPAA violation?

    Was this a rant? No, it's an attempt to influence the other way after reckless statements feigning factual made by misinformed yet opinionated posters.

    When in doubt, choose patient safety, (assuming your own has been considered), even if it means getting a door slammed in your face, it's worth the ones you help. Plus, a patient able to get to the door with the strength to slam it can be seen as a favorable outcome, much better than the alternate described above.

    ETA I think you might have meant with "it's all good right up until it isn't" is related to clinician safety, not patient concern. Employee safety must s,says be considered. These are either known patients or at least met face to face by associates, neighborhood, setting and patient psycho social history is taken into consideration.

    It's home health, we take calculated risks as a nature of the business. With checking on the unfortunate geriatric living in a populated visible community, safety was considered, it's always considered.
    Last edit by Libby1987 on Aug 18
  10. by   Susie2310
    Libby, what is a "populated visible community?" I believe that you had previously typed "rural community."

    It sounds as though your home health agency functions also like a public health nursing agency.

    Obviously, we all live in different areas that consist of differing demographics of patients. I'm sure that hospital referrals for home care services vary from area to area according to patient condition/co-morbidities/family members available to help, and local nursing facilities available. In my area, there are acute rehab facilities and skilled nursing facilities which can receive very fragile/debilitated patients without family members/significant others to stay with them at home to help them, who will require further nursing care after hospital discharge. It sounds as though it is common in your area for this demographic to be discharged home by themself from the hospital, with an RN to provide periodic medically necessary home health services. Is this because there are no acute rehab/skilled nursing facilities available nearby, or because these patients prefer to be discharged to their homes even if they live alone? How do these patients who live alone manage during the rest of their recuperation from their hospital stay, when an RN or other caregivers are not present in their homes?
    Last edit by Susie2310 on Aug 18
  11. by   JKL33
    Quote from Libby1987

    It's home health, we take calculated risks as a nature of the business. With checking on the unfortunate geriatric living in a populated visible community, safety was considered, it's always considered.
    I give all of you credit for all you do to care for those in the community!

    Thanks for your answers.
  12. by   Libby1987
    Quote from Susie2310
    Libby, what is a "populated visible community?" I believe that you had previously typed "rural community."

    It sounds as though your home health agency functions also like a public health nursing agency.

    Obviously, we all live in different areas that consist of differing demographics of patients. I'm sure that hospital referrals for home care services vary from area to area according to patient condition/co-morbidities/family members available to help, and local nursing facilities available. In my area, there are acute rehab facilities and skilled nursing facilities which can receive very fragile/debilitated patients without family members/significant others to stay with them at home to help them, who will require further nursing care after hospital discharge. It sounds as though it is common in your area for this demographic to be discharged home by themself from the hospital, with an RN to provide periodic medically necessary home health services. Is this because there are no acute rehab/skilled nursing facilities available nearby, or because these patients prefer to be discharged to their homes even if they live alone? How do these patients who live alone manage during the rest of their recuperation from their hospital stay, when an RN or other caregivers are not present in their homes?
    By populated visible community I meant that it wasn't a secluded home that I went to.

    I don't see where I typed rural community so not sure what you're referencing.

    No, we don't function like a public health agency. We are affiliated with a larger healthcare system and work collaboratively for the well being of our patients. Prior to that I worked for a free standing HHA that had deep ties to the community and also worked collaboratively with the hospitals, MDs and local healthcare community.

    Patients who live alone and/or lack resources often refuse SNF and/or don't qualify ie ED visit only and going back into the community is their only option. Anecdotally, at hospital discharge, the majority refuse to go to SNF and choose home. Those who agree to home health and live alone, with a frail spouse etc will get what we call a drive by if we can't reach them by phone. We try do everything we can to account for them.
    Last edit by Libby1987 on Aug 18

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