New QA nurse in home health

[moskalyn]

I recently started a job in home health as a QA nurse, the DON wants us to write and sign orders for nurses out in the field, particularly an LPN, I found out that LPN's can write their own orders but this was not the case at this agency, it makes me nervous to do this. What is the liability, I did not speak to the MD nor did I see this patient. Is this the norm for home health. Also, if there are missed visits, anything that is missing from the chart we are suppose to fix. I feel that this goes against what is right!! Any suggestions

[RubyRN,CHPN]

In my state the LPN can write the order but requires an RN Cosigner.

The RN Cosigner is always the LPN's clinical manager at our agency.

We do have a LPN office nurse who will follow up on our outstanding orders with physicians that are faxed; however, she defers only to the nurse who requested the orders originally when they are transcribed verbatem into the record for signature. Otherwise, if she is taking an order she requests her direct clinical manager to cosign it.

She does a very nice job for us and is a valuable part of our team in keeping continuity of care for our pt's. so orders don't get missed and pt's. get seen without a break in service following SOC.

[HealthyNurse]

This has to do more with the Medicare Conditions of Participation. Per the Medicare COPs, it must be a qualified RN or therapist that makes ANY changes to the plan of care. So technically, an LPN cannot make a change to the plan of care, which includes a verbal order for treatment changes or medications. What this means in states in which LPNs are permitted to take verbal orders, is that they can still take the order, but there must be an RN who is responsible for oversight of the care of the patient that co-signs it. This is acceptable per the COPs. Many home health agencies will delegate the co-signing of LPN orders to the clinical manager. In my agency, the clinical managers review all interim orders anyway, so this makes sense. I've not heard of QA nurses taking on this responsibility and I guess I would have to question as to if a QA nurse is responsible for oversight of the care of the patient. A clinical manager is ultimately responsible for the care of all patients on their team. If clinical oversight is included in your job description, I could see how this responsibility may go to you.

I am not sure what you mean by the missed visits. Are you saying that you add in a visit? That would not be okay at all...that would be fraud.

[moskalyn]

The agency I was working for hired us to review the charts. Some of these charts were 1-1 1/2 months behind, meaning paperwork was not handed in in a timely fashion. The LPN would write down at the bottom of her visit note in the communication part with MD, the orders she received. We would have to take that(we the QA nurses)and put it on a paper order then it was faxed to the MD for signature. I was not comfortable with this, again these orders were going way back. I called the IDPR and spoke with the nurse and she stated in the state of Illinois LPN"s are allowed to write orders that are received, we the RN's would need to supervise them. Again this was not the case. Also, to explain the missed visits, if a visit was not made for that week(for whatever reason) we would have to write the order missed visit per pt. request due to family situation. Usually it was due that nurse being on vacation and it was not covered. We would also review the oasis SOC, Recerts etc., and be requested by the DON to change things.

Another thing they were doing was on SOC the field nurse would take a list of medications and deliberately leave a few off so that they could be added during the episode to look like they had problems during that period to justify keeping on service. The list goes on, there were other things but, I have since left this position, I felt my license was on the line. You mentioned the word fraud, hmmm, what do you think??

[RubyRN,CHPN]

That much better explains the situation, not a true QA position but more like a CYA position for them. Sounds like they were way out of compliance and looking for someone to straighten things out or go down with them as well.

[moskalyn]

That's what I was worried about, feel better that I left but irked with what's going on there. No wonder why our health care system is such a mess. I would love to report this but worried about the ramifications.

[caliotter3]

There was nothing to stop the field LPNs from writing the order up on a supplemental/telephone order form but laziness and no clear direction from the agency supervisors. All you should have had to do was to verify the order telephonically with the doctor and/or send it by fax for the doctor's signature. Putting it on the 485 without verification or signature from the doctor was certainly not correct, as the practice you described about leaving meds off the initial POC and being untruthful about the missed visits. It is probably best that you left that position. It would have taken little effort to be in compliance without resorting to bending the truth.