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I checked with a local accrediting agency. HHAs are certified like CNAs in my state and can empty foleys, JP drains, and perform simple dressing changes as long as there is documented training with each aide and new patient by an RN. I can't believe they can't even give a bath in other areas... that is their main job! Wow. Maybe you are referring to uncertified personal care assistants/companions?

I am in the state of Indiana. State regulations state that HHAs are not to do anything "invasive." Would this include emptying JP drains? My director has asked me to teach the HHA how to provide JP drain care and put it in her careplan. I don't really have a problem with that as JP drains are pretty common sense, but I want to make sure it is okay. I will be visiting the patient weekly to monitor the surgical wound and drain sites. This is a Medicaid-only case. Opinions?

Central Indiana. $22/hr, no bennies, $0.32/mi. Bonus for being on-call by day (I haven't been asked yet to do it so I don't know what that stipend is... the last agency I worked for paid an extra $150/wk on-call). I'm still in training so I don't know what my load will be. My documentation and phone calls are expected to be done while I am in the home which means I'm not expected to make more than a reasonable number of visits a day and my drive time is paid, which is nice because some patients are kinda far. I'm a newer nurse so this kind of pay seems reasonable to me... I'm amazed at how much of you seem to be able to make!

I posted a while back about a new job I got, and it was recommended that I find a new agency. My frustration led me to do just that about a month ago. I started last week at a new place, but it is small and has only been around for a year. They do a mix of private pay, Medicaid, Medicare, and home infusion. The owner (also an RN) and DON seem wonderful, professional, honest, and willing to do what it takes to be a respectable company... but since they are new, there are a lot of loose ends at the moment. The DON is not very familiar with Medicare and the owner is just way too busy making visits at this point. I don't want to bother her with endless questions, so I thought I'd tap you wonderful people as a resource. :) Before I start, let me just say I absolutely love home health. I'm never bored, and I love the independence and feeling like I have more influence than I do at the bedside. I feel less like a cog in the wheel and I get to know my patients. I hope that I am able to make a life-long career out of it. Okay, so my questions! 1) Diabetic patient. Has a glucometer, doesn't take sugars regularly or at all. What do you document on the Oasis (or at least the computer program we are using)? 2) Mixed case. Someone describe this to me so I understand it. 3) Non-compliant diabetic Medicaid patient. Frequent hospitalizations... noncompliant with meds. Discharge, or continue to provide an aide? How do you document if you are keeping the patient? 4) What happens in Medicare if a bedbound patient develops a pressure ulcer and peri-area excoriation under your care? The one I'm thinking of refuses to be turned, changed as often as needed, etc... the ulcer was inevitable. 5) Patient getting Medicare wound care and an aide through Medicaid. Cancels the aide often. Not compliant enough with advice to allow the pressure ulcers to heal. What to do? Discharge? If we do, he will get no wound care and end up in really, really bad shape. 6) Good publications to subscribe to and/or read to keep up on industry practice, common company policies, reimbursement trends, etc...? Except in really obvious cases where patients request outright fraud or enable it, I often feel like discharging is extreme.... I feel like I'm abandoning the patient. What we give them is more care than they would get without us, so I am conflicted. Not to mention, companies don't like it if you are discharging left and right and not making them money. LOL Non-compliance is so common and I am having a hard time finding the fine line between honest documentation that covers my butt and well... the alternative. Doesn't Medicare know that most patients aren't willing to do what it takes to get better? It seems every nurse handles this stuff differently, at least the few I've come to know in home health. Thanks for the advice, folks...

Thanks, everyone. Unfortunately, it is the only job I could find. The DON said she will make sure I get patients that aren't abusing their narcs or patients without narcotics, so that makes me feel a little better. I don't care what the agency does so long as my name isn't on the chart as case manager. The DON is sympathetic, but the owner of the company does not want us reporting things because the vast majority of our clientele is selling their narcs for money to live on. We are so small that we can't afford to lose business. How do you guys document things when you have similar findings? And what state are you in?

That is a great perspective, Susie. I do think a course covering healthcare law would be beneficial as well, but I hate to contribute to the problem of credential creep that seems to plague healthcare. I'm not sure a BSN is needed to do most types of nursing, especially considering it doesn't offer any more clinical knowledge or advantage in a clinical setting. A BSN should be noticeably different from the ADN... moreso than it is now. It should require more advanced clinical and scientific study. I guess I'm of two minds on the issue. I can see the benefits of making the program more rigorous-- namely respect from the rest of the medical professions and a broader range of career opportunities. But on the other hand, some people just don't want to do anything other than bedside nursing, and they shouldn't be required to take all those superfluous classes. I guess the way it is now is pretty adequate, all things considered. I still think it is awful that hospitals require a BSN these days, and offer no benefits for having spent an extra two years in college. As another poster has said, these debates have been going on for decades now. I don't see it being resolved anytime soon, especially since there are so many options for nurses wanting to advance their education. The workplaces will eventually see how dumb it is to require a BSN and start allowing LPNs and ADNs to work at the bedside again.

I got my BSN in an accelerated program at a respected nursing school in my state. If you have a bachelor's, in ANYTHING, you are eligible for the program. That means that basically it was an ADN course with a few classes in management and public health thrown in. It was very competitive and it took me two tries to get in, even with a high GPA. What really ticked me off was that my pharmacy courses weren't good enough as prereqs. I have completed all my coursework for a PharmD, but I didn't do my residency. (My BA was in philosophy, quite by accident... I took the classes for fun while in pharmacy school to boost my GPA.) I didn't finish pharmacy school for a number of reasons. Politics, bankruptcy, divorce, depression... what can I say.... life happened. I took very intensive anatomy, physiology, and pathophys courses for pharmacy, but because they weren't taught the same way that they are taught for nursing, I was required to retake them. I'm not dogging nursing school as it had its own challenges, but it was incredibly easy compared to pharmacy school. I'm not even thinking of all the advanced math and chemistry... it was simply much more academically rigorous. The nursing school, on the other hand, didn't seem to care if you could write very well or do complex analysis with proper citations. The exams were 50 questions tops and were very simple. In pharmacy school, exams were often 100 questions and included essays, even for basic courses. The medicinal chemistry courses were hell on earth! My nursing school integrated pharmacology into the courses and I think it was detrimental. Many professors were teaching outdated information and in some cases, misinformation! When classes are integrated, not as much time is spent on the details and complexity of a subject. When they are addressed in a separate class devoted to a subject there is a much greater opportunity for learning. You can learn the basics of pathophys and pharmacology when they are taught together along with a general systems review, but you can learn so much more when they are addressed separately and then treated as assumed knowledge in a higher level course that teaches how disease states are managed. I suppose I am biased on this topic, but I do think that nurses should take more in depth pharmacology. I really don't see a lot of difference between ADNs and BSNs in practicality, but if you are going to speak the language of academia or work in a hospital, you should have a BSN. It is unfair that ADNs are not treated with the same respect as BSNs, if you can call what a BSN gets respect. Personally, I think the entry level degree should be the ADN. BSNs should be reserved for management or jobs that require more paperwork (like case management). I also think the BSN program should be noticeably more rigorous than the ADN, and at present, it obviously is not. There is a reason doctors and pharmacists look down on nursing.

I am new to home health, and I just started working as a case manager at a very small agency that does mostly non-skilled patients (only about 10% skilled) and ALL their patients are Medicaid. It is a family business and most of our clients are friends of the family that owns the company. Let's just say it is a very "urban" population. Here's my situation: I am a nurse in recovery and I am a part of my state's monitoring program, so I am paranoid about narcotic issues. We have several patients where it is obvious to me that they are selling their narcotics. If they ever get caught, I would be liable in any way as an accomplice or something? My DON says that with non-skilled patients, we aren't responsible for their meds since we don't set them up and such. However, we still do medication reconciliation with the recertification visits. I do my medication reconciliation by looking at all the bottles and comparing them with our records in addition to asking the patient (because the patient doesn't always remember what has happened in two months). The other nurses just ask the patient. Using my method, I have discovered missing bottles of narcotics and bottles that were empty long before they should have been, and I don't think the patients aren't overdosing on them... they are selling them. One of our skilled patients let a drug deal go down right in front of me and I was allowed to discharge that patient, but I was chastised for informing the prescribing physician that there were narcotics missing from another non-skilled patient's home. If we start tattling on all our patients that do this, we would probably lose a lot of business, so I understand the hesitancy in being too harsh.... but I am just trying to CMA if you know what I mean! What, in your opinion, is my responsibility as the nurse doing the recertification and assessment? Would you report that meds were found missing for a non-skilled patient?

Has anyone had success in offering blood or hair to prove sobriety after a dilute screen? Or perhaps a request to evaluate the sample with more sensitive lab techniques? After reviewing my program's policies, which are rather unclear I should say, it looks like they could do anything from *nothing* to preventing me from working and reporting me to the Board. If they take a disciplinary action that far, I want to have a way to defend myself. I did something stupid, yes, but I don't think it is reason to prevent me from working as I have not been using. I anxiously await the call sometime this week... I am sick over this, but I am trying to practice the things I have learned. Serenity prayer, here I come! Wish me luck!

Hello, my fellow recovering addicts and alcoholics! I have been sober for 8 months now, after a relapse following my mother's death. I have been in my monitoring program for almost two years now. It is amazing how life improves when one doesn't turn to drugs for escape. I was paranoid, insecure, and never able to whole-heartedly pursue my goals when I was smoking. Although some days I still have cravings, I am convinced that life is better without it and I am pretty good at using my coping skills and support system to get through rough times. I have made an amazing network of true friends while in the program and I wouldn't give that up for the world. When I was using, I had no friends and I constantly isolated myself when I wasn't at work. Here is my really embarrassing situation: I recently got offered a job as a home health case manager for a very small home health agency. I honestly never thought I'd never be able to find a nursing job until I was done with my monitoring program.... so YAY for that! :) I had been applying non-stop, but when it comes to the interview and revealing my participation in my program, I either get "I'm sorry" or I get the run around never to hear from the employer again. I am so thankful that something came through for me and I do not want to mess this up! I have gotten approval from my program for this new job and I start sometime next week. However, I am now scared crapless that I have messed this up for myself. They popped me twice last week. When I turned in my sample the second time, it appeared pretty pale and dilute (pastel yellow). This is because (I am really embarrassed to tell this but here I go) I had taken 10mg of Lasix earlier in the day before I logged in and found out I had to test. I missed a couple birth control pills last week and I needed to take Plan B, which made my breasts really sore that day. I have kept my mom's old Lasix around to take a half tablet when I feel bloated. It really does and did help. Unfortunately, it made my urine dilute too.... I feel so dumb and I really hope I won't have to explain this to my program. I'm pretty sure I'd get in trouble for taking something that wasn't prescribed. Before you are too hard on me, you should know that I am well aware of the health risks of taking Lasix. I only take it once or twice a month, and then only 10 mg, and I haven't had any muscle cramps or ill effects. I had one other dilute early this year (from simply drinking too much water one day) and the letter says they would turn me over to the MRO and have me see a nephrologist if it happened again. I am so scared they will rescind their approval for my new job. I am prepared to offer my hair, blood, and soul to prove I wasn't using! I have already thrown away the Lasix so I am not tempted to take it again when I feel bloated and then get tested. I can't afford to be in this position again! I am a nervous wreck and I have called my sponsor twice already today. I can't change what I did, and I shouldn't worry so much about consequences before they even happen. But it is hard not to. I'm hoping hearing some of your stories will ease my mind a little. What does your monitoring program do when you have a dilute? Has anyone ever been denied a job for a dilute sample?

Attention home health case managers! :) After being out of a job for a lengthy period of time, I lucked out. I am going to be hired as a case manager for a small home health agency. The problem is, I have no experience in case management, and I am a fairly new nurse with less than a year bedside experience. I am a BSN and was also in pharmacy school for five years, so I am very familiar with the medical side of things. I just don't know much about case management. I want to be as prepared as possible. I am somewhat familiar with what a hospital case manager is responsible for, but I really don't know how those duties differ for a home health case manager. This agency provides services only to Medicaid patients. And I know next to nothing about how Medicaid works and how reimbursement is evaluated and provided. I am aware of the various certifications a case manager can apply for, and I plan to get these as soon as possible. So...What do home health case managers do, exactly? What should I do or study to excel? Are there any sites on the web that you have used as a case manager to help you do your work? Your advice, tips, helpful references, stories, and experiences are exceedingly appreciated!

Thanks for the replies. It turns out I was not offered a position at the drug research company... bit of an ego kill, but at least I won't have to make a choice. I'm just focused on getting this nursing home job now. I am still scared, so please tell me some encouraging tales from the LTC world!

So, I'm a new nurse with only six months medical-surgical experience (organ transplant) who stupidly self-reported to her state board and is in a monitoring program. Assistance program, my butt! I've been forced to look for a new job as my old one won't accomodate my narcotic restriction. I have a restriction on my license so that I may not pass narcotics, which has made the job hunt difficult. I have found two options and have gotten past the first interview with both companies: Work for a drug research company as a lab assistant, with the goal of eventually working my way up and making more money. I know from friends who work there and from the interviewer that this company prefers to advance employees from within, and that nearly 80% of their long term employees have started out as lab assistants. I have some pharmacy school under my belt inaddition to my BSN, so this option appeals to my long range career goals. I would probably want to work here for a very long time. But the pay sucks for now. --or-- Work for a nursing home. Pay is great, working conditions suck. Long-term prospects are not so good, but it would satisfy the requirements for my monitoring program (but so would the other job) so my restriction can be taken off. I would want to leave this job and go back to bedside nursing in the longer term, but I know I will get burned out on that in a few years anyway. Decisions, decisions... money or career? What have been your experiences in getting a good hospital nursing job after having had worked in a nursing home? What is working in a nursing home like? Anyone in research that can tell me more about that industry? I hear nursing homes are hell on earth. Thanks to everyone for your input!