curiousauntie

I worked at my last hospice job for 7 1/2 years. During that time we were surveyed...not once! Honestly, we did not have one Medicare audit or one visit from the state DOH! We did have CHAP audits, 3 or 4 times, but coming from LTC, they were a cake walk from what I was used to. We also had a Medicare compliance consultant who visited at least monthly to do chart audits and supervisory visits with the nurses.

From a sign my sister has over her desk..."Poor planning on managements part does not constitute an emergency on my part". Read it, learn it, live it!

I work for Heartland Hospice. It is owned by HCManorCare, who has LTC, Subacute rehab, AL, Home Care and Hospice and even out patient Pt/OT offices. How good the office is depends on how good your administrator and DPS (director of professional services, the DON) is. I work under one of the best DPS's I have ever had. The company is very compliant with Medicare guidelines and corporate audits are done at least 2 times a year to insure we are compliant with eligibility. That said, we've also had a bad director or 2 in the many years I've with them. Those were bad times. The best I can say is try to get a feel for the office when you interview. And please don't discount Heartland just because it is "for profit". There is a large "non profit" in our area who has huge turnover, doesn't supply the extras to the pts that we do (nice tab diapers, pull ups, nice absorbant chux, etc). And over the past year, we have gotten a lot of transfers from this "non profit" due to their service failures. From not providing a home health aide when the family wanted/needed them to, as one family member told me, employing the most cold hearted people the family member had ever met. Good luck on your move and job search!

There's no reasoning except they needed a scapegoat to show they addressed the problem. You need to write a statement that can be attached to the write up stating your 3 weeks of employment, that the mds is just now due and how you plan to address his changes. Never just sign a write up and leave. Always write out your side of the incident. If you are too upset at the time, write on the comment area to see attached statement, go calm down and write the statement before the end of that day.

The local hospital will be laying off another round of nurses in June....I am hopeful, although I don't think hospital nurses could handle the patient load on a sub acute floor! I like that last sentence. I worked in LTC for 22 years befor moving to hospice. I saw many a hospital nurse come and go because they thought LTC would be soooo easy! They were so used to treat em and street em...not having an actual relationship with the resident and family. Or the fact of a 30:1 or more pt:nurse ratio. And in Sub-acute, the mis of pts...AAOx3 to demented, surgical pts to long term IV , g-tube, nasty, wound vac type wounds. And they all "belong" to you. I started my nursing career in LTC in the mid 80's, moved to sub-acute rehab in the mid 90's and to hospice in the mid 00's. I be seen a lot of nurses come and go in all 3 areas.

Very simply, if he was not to be sent to the hospital, he should have had a DNH order. In the middle of an emergency you don't have time to read POLST forms. That's why we have DNR, DNH, DNI orders. And with no way to speak to a family member or MD, what else were you to do? And I agree that suspension was WAY harsh. Your director obviously doesn't see a need for education, which makes me question her ability to adequately lead a team.

Our goal is to have the nurse there within 4 hours of receiving a referral/md order. No admission nurse, but if possible the case manager who will have the patient will do the admission, or the on-call (me;)) will do it in the evening or weekend. I do the initial assessment, get the legals signed and fill out 3 hours of paper...then there is the follow-up in 24-48 hours. The nurse doing the admission also calls medications into Hospice Pharmacia, gets durable medical equipment delivered and calls the hospice physician and the attending physician to verify orders. Seems like each one takes 3 days, but can actually all be done in about a 5 hour period, with the exception of the follow-up visit.

We have 2 massage therapist who do wonderful work. I know of one other office who has an on-call music therapist and our office has a vigil volunteer who provides music therapy once the patient is actively dying. I think both modalities are wonderful, as I have witnessed both of them doing what they do best. The peace that comes over a patient who is hours or minutes from death when the vigil volunteer is at the bedside is just breathtaking. Your company needs to rethink their policy so you can continue to treat the WHOLE patient, not just the physical patient.

We cannot order meds in a facility. We can leave "Suggestions for care from Hospice nurse" with what we would use, but cannot call the MD and actually get the order. The facility nurses have to do that as the facilities say we are not their employee and their nurses cannot take an order that we get from their doc. I'm not sure if this is a State thing or a regional thing but all the nursing homes in our territory do it this way. Most of the nursing homes do not want us ordering Morphine or Lorazepam until the patient needs it and yes, I think it is because they don't want them in the narc boxes on the unit to be counted 3 times a day forever...or be there forever then all of a sudden come up short in the narc count. We are also absolutely forbidden to transport ANY medication, especially narcotics, from a pharmacy to a patients home. This is a company-wide policy (and we are a rather large national company with everything from assisted living, home care, LTC, out-patient rehab and hospice). It is a safety issue, and believe me, when I have to go into sketchy areas I am glad I am not allowed to carry even a Tylenol to a patients house. So that precludes the whole "emergency box" to borrow from for the nursing home patients. All home patients get a comfort kit on admission. To the OP, just a question (asked with an incredulous look on my face) What kind of hospice gives you grief when you want to order comfort medications for THEIR HOSPICE PATIENT???? There is actually a hospice in business who doesn't want their patients comfortable at end of life? I wonder what their definition of Hospice is??? Our patients are seen frequently, especially once they start to decline and as soon as either our case manager sees the signs or a facility nurse calls us to tell us of the signs, we get the Morphine, Lorazepam and Atropine drops ordered as quickly as possible. If they aren't used, so be it, but better safe than sorry. And we don't send comfort kits, but just order the individual medications as most facilities won't allow the Haldol from the kit, either.

I'm hoping you mean that NOT having a DNR for an Alzheimer's pt is immoral...I get that feeling from the rest of your post.O:-)

tammyG. That's a scary thought. I can't count the number of times that care kit was a difference between an easy and a horrible death. As a full time on-call nurse, the meds in there; morphine, ativan. haldol and compazine are frequently needed when there is no way to get them in a timely manner. Like 2am with a pt who has just started actively dying and a family with their phone ready to call 911 if I don't get the symptoms managed NOW! That kit is often the difference between a comfortable death at home and a torturous trip to a hospital.

What about liquid haldol? We have it in our comfort kits and it works wonderfully. 2mg/ml. We usually start with 0.5ml/1mg. I personally wouldn't want to try to stick a combative, agitated pt. IM or SQ.

I'm 40 hours a week, salaried, and with 7 years seniority, at $33/hr. But I lost OT when I changed to on-call, so actually lost pay each week as I always had between 3-6 hours of OT each week when I was a case manager. But as on-call, my mileage starts at home, not after the 20 miles it is to the office. And I get paid mileage to drive home from the visit too.

The tests are varied, with (I think) questions from 5 different aspects if hospice. I do remember ethics, medications, legal aspects, disease process...the test hand book breaks it down. And for each of the testing periods (there are 4 "test windows" each year) there are numerous individual tests. So the one you take may be heavy in oncology and the person next to you may have one heavy in disease process. Read the hand book, and when you feel you are ready, take the practice test. It cost $25, but will score you in each section and tell you how likely you are to pass each section. Very helpful un letting you know where you are still weak.

Our company has 2 dedicated on-call nurses. For the past year, I have been one of them. I work 7 days, Mon evening to the following Mon morning, covering the hours the office is closed, including Sat-Sun. The other dedicated on-call nurse works the next week. I was a case manager for 6 years when we only had one on-call nurse, so the case managers would cover the other week. I usually ended up doing 2 week days and one weekend day. We are a small office, with 3 full time case managers and one part time case manager. When there was only one on-call nurse, we would help each other out if the nurse who took call had a bad night. All it takes is one patient going bad, or having problems in the middle of the night to disrupt your sleep. (and in my state, driving if you have not had sleep in the past 24 hours is considered "impaired" and can get you a "driving while impaired" charge if there is an accident or ticket...and it is treated as if your had been drinking!) During this time I found if I could have the morning off, just to sleep for 3 or 4 hours, I could see a couple of patients in the afternoon. I also found that the case managers made sure the patients were completely taken care of for symptom management, medications, supplies etc. before they were done in the afternoon. I HATED myself if the on-call case manager had to deal with any problem that could have been dealt with before the end of the day. I know that a lot of problems cannot be anticipated, but a lot can, and should not be left to the on-call to deal with, especially if that on-call is a full time case manager, not a dedicated on-call nurse.