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"When you are working as a HHA, you are not working "below your license." Part of your training as a nurse is to assist patients with ADLs and personal care needs definitely within your scope of practice. Instead of feeling insulted, try looking at what you get out of it. How they pay you is another story. You are required to act to the level of your training and education. They should be paying you for what you know, not what you do." I am in agreement with Karen. Every one of use have been trained in Nursing 101 how to bathe a patient and yes it is well within our scope of practice to do so. When I was in the role of Supervisor, I went out to provide personal care to patients because of a lack of staffing and enjoyed every minute of. I didn't think of it as being beneath me to do so. (The patients were impressed the Supervisor came to see them and even chuckled when I ended my visit with more powder on me than on them! They couldn't wait to tell their nurse about it.) Nursing is a broad spectrum profession.....we wear many hats.....and that of a HHA at times is one of them. Agencies should pay their staff according to their position for any care given. Agencies who pay their nurses an aide's hourly rate for a HHA visit are looking at it from a reimbursement perspective as opposed to an obligation persepctive. The committment was made to provide HHA services and an agency must meet that obligation.

In our agency we mandate that an Agreement to Treat (or as others may call it a consent to treat form) be completed and signed prior to putting hands on the patient. We have recently had some discussion among the ranks regarding this. Some are saying the patients allowing us into their home is "implied" consent for us to evaluate and then determine whether or not they will be taken under care. Once it is determined the patient is approriate for home care then a consent would be signed and they would be admitted for services. If they are not appropriate for home care, we notify the MD and if in an unsafe situation Adult Protective Services is notified as well. We do not have a consent signed and they are not admitted to service. We document the interventions made in a note. Others are saying we must get the patient to sign an agreement before evaluating the patient or laying any hands on them. (which is what we currently are doing) The staff feels that once this consent is signed....then they are indeed a patient under service with us and we are obligated to provide home care services regardless of our findings. What do other agencies do? How do you interpret the mandate there must be a patient consent for treatment signed? I look forward to your response. Thanks

The following was shared with me today and tugged at my heartstrings. It made me stop and consider. When an old man died in the geriatric ward of a nursing home, it was believed he had nothing left of any value. Later when the nurses were going through his meager belongings, they found this poem. CRABBY OLD MAN What do you see nurses? ..........What do you see? What are you thinking.........when you're looking at me? A crabby old man..........not very wise, Uncertain of habit..........with faraway eyes? Who dribbles his food..........and makes no reply? When you say in a loud voice...........I do wish you'd try! Who seems not to notice..........the things that you do, And forever is losing............a sock or a shoe? Who, resisting or not...........lets you do as you will. Who bathing and feeding...........the long day to fill? Is that what you're thinking?...........Is that what you see? Then open your eyes nurse.........you're not looking at me. I'll tell you who I am..........as I sit here so still, As I do at your bidding...........as I eat at your will. I am a small child of ten..........with a father and mother, Brothers and sisters............who love one another. A young boy of sixteen............with wings on his feet, Dreaming that soon now...........a lover he'll meet. A groom soon at twenty..........my heart gives a leap, Remembering the vows..........that I promised to keep. At twenty-five now..........I have young of my own, Who need me to guide..........and give a secure happy home. A man of thirty..........my young now grown fast, Bound to each other............With ties that should last. At forty, my young sons..........have grown and are gone, But my woman's beside me..........to see I don't mourn. At fifty, once more..........babies play 'round my knee, Again, we know children..........my loved one and me. Dark days are upon me..........my wife is now dead, I look at the future..........shudder with dread. For my young are all rearing..........young of their own, And I think of the years..........and the love that I've known. I am now an old man..........and nature is cruel, Tis jest to make old age..........look like a fool. The body, it crumbles..........grace and and vigor depart, There is now a stone..........where I once had a heart. But inside this old carcass..........a young guy still dwells, And now and again..........my battered heart swells. I remember the joys..........I remember the pain, And I'm loving and living..........life over again. I think of the years, all too few..........gone too fast, And I accept the stark fact..........nothing can last. So, open your eyes people..........open and see, Not a crabby old man..........look closer, SEE ME! Remember this poem when you next meet an older person who you might brush aside without looking at the young soul within. We will all, one day, be there too! The best and most beautiful things of this world can't be seen or touched. They must be felt by the heart.

The following was shared with me today and tugged at my heartstrings. It made me stop and consider. When an old man died in the geriatric ward of a nursing home, it was believed he had nothing left of any value. Later when the nurses were going through his meager belongings, they found this poem. CRABBY OLD MAN What do you see nurses? ..........What do you see? What are you thinking.........when you're looking at me? A crabby old man..........not very wise, Uncertain of habit..........with faraway eyes? Who dribbles his food..........and makes no reply? When you say in a loud voice...........I do wish you'd try! " Who seems not to notice..........the things that you do, And forever is losing............a sock or a shoe? Who, resisting or not...........lets you do as you will. Who bathing and feeding...........the long day to fill? Is that what you're thinking?...........Is that what you see? Then open your eyes nurse.........you're not looking at me. I'll tell you who I am..........as I sit here so still, As I do at your bidding...........as I eat at your will. I am a small child of ten..........with a father and mother, Brothers and sisters............who love one another. A young boy of sixteen............with wings on his feet, Dreaming that soon now...........a lover he'll meet. A groom soon at twenty..........my heart gives a leap, Remembering the vows..........that I promised to keep. At twenty-five now..........I have young of my own, Who need me to guide..........and give a secure happy home. A man of thirty..........my young now grown fast, Bound to each other............With ties that should last. At forty, my young sons..........have grown and are gone, But my woman's beside me..........to see I don't mourn. At fifty, once more..........babies play 'round my knee, Again, we know children..........my loved one and me. Dark days are upon me..........my wife is now dead, I look at the future..........shudder with dread. For my young are all rearing..........young of their own, And I think of the years..........and the love that I've known. I am now an old man..........and nature is cruel, Tis jest to make old age..........look like a fool. The body, it crumbles..........grace and and vigor depart, There is now a stone..........where I once had a heart. But inside this old carcass..........a young guy still dwells, And now and again..........my battered heart swells. I remember the joys..........I remember the pain, And I'm loving and living..........life over again. I think of the years, all too few..........gone too fast, And I accept the stark fact..........nothing can last. So, open your eyes people..........open and see, Not a crabby old man..........look closer, SEE ME! Remember this poem when you next meet an older person who you might brush aside without looking at the young soul within. We will all, one day, be there too! The best and most beautiful things of this world can't be seen or touched. They must be felt by the heart.

This is a tough question to answer. Having done home care for over 20 years, and still loving it I think I would say; 1. Never think you are suppose to have all the answers. There is always something to learn. Don't be afraid to say I don't know and then seek the answer. 2. Feel confident regarding your clinical skills. Good assessment skills and critical thinking is a must. 3. Do know your mission is not to cure all.....but rather remember home care is a bridge. Some injury or illness caused an interruption in your patient's life. Your goal is to provide them with the knowledge of how to get back to where t they were before the injury or illness occurred....or as close to it. With some you succeed....with others you don't. 4. There is no place in home care to be judgemental. Not everyone rushes to be the first to move into the low housing development that is infested with roaches and rats. Not everyone can put in the ramp, stair lift, modify bathrooms etc. to make them safer in their homes. We are fortunate that we do not have to make the decision regarding buying my medicine or paying the rent. Be empathetic to where the patient is now....and accepting. KNow we are ministering to them on THEIR turf now.....not the sterile rooms of the hospital. 5. Do know your days will be a roller coaster of emotions.....frustration, excitement, sadness, joy, irritation, fatigue....much like in any other area within health care. The key is to be able to put your head to the pillow each night thinking you have made a difference in at least one person's life.

"Oh that's Sadie....she's the new top dog on the unit."

Care of a vac is a routine part of patient/caregiver education at the START. Before we consider accepting a patient for service, we ask if there is a caregiver available AND willing to be taught the vac. If there isn't we do not accept the patient. Part of the basis of home care is the patient takes an active part in their care. Patients and/or family members are taught how to check the dressing for leaks and what to do when one is found. If they are unable to fix the leak, they are instructed to apply a "rescue" dressing (wet to dry normal saline) and notify the agency. A nurse is sent out to reapply the dressing the next day.

My agency provides the flu shot to any of our home health patients that want to receive it. This is a reimburseable procedure by Medicare. As Medicare is federal, there is no reason the patient cannot receive it in the home. I am only clear with my State regulations so cannot speak for your state. Is there something in your state regulations that prohibits it? In addition we also give it to any caregiver who wants to receive it....whether they have Medicare or not. If they are a Medicare recipient we bill Medicare. If they are not, they pay for the injection and we give them a receipt to submit to their insurance carrier for reimbursement. We have assisted living facilities as well as senior apartment complexes call us each year to set up clinics for their residents. Again....there is no charge for Medicare residents. Not only are we providing a service for our home care patients, but we are making our presence known in the community. Keeping one of them out of the hospital from flu related complications makes it all worth it.

Thanks all for your input. We have raised the same questions Linda1208rn did on mulitple occasions, hence why we have not gone this route as yet. I read notes and see where the patient's sats have dropped following a therapy session, but no documentation regarding what the therapist did. In my mind this is a worse scenario than having not done one at all. I am not going to be rushing in and revising the policy but will bide my time regarding this.

I am finding a number of our therapy groups whom we contract with for supplemental support are evaluating the patient's O2 sats as a part of their routine vitals. This has not been a policy of our agency to do so I am constantly telling them they need an MD order to cover this. Now, our agency is taking a look at this process and are considering making it a policy for all our patients......regardless of the disicpline following the patient. What do others think about clincians using a pulse oximeter to obtain O2 sats as a routine part of assessing vital signs?

Kate love your wish list. I have found it amazing the number of applicants who come into the office and seem to have all the right answers to interview questions......yet are the total opposite when hired. Not everyone are good test takers.....so I only use a test as a guide. Situational questions seem to help in evaluating their assessment and critical thinking skills, and often gives me an idea whether they really know what they are talking about. It forces them to think on their feet. Nothing however is a sure fire proven tool.....so more times than not I have relied on my 'gut'. It is amazing.....my gut has never proven me wrong!

In my agency there is an area on the visit note where the nurse can document communication with the MD.....(MD name, what the issue was, outcome of the conversation) for something found that visit. If the MD was not available at the time of this call or additional communication is necessary, then all subsequent communication is documented on a 'Narrative Note' to include date, time, conversation and outcome. All are a part of the patient's medical record.

Another thing I do for the staff in the way of a "mini in-service" is to send out a weekly flier regarding a topic. An example is clarifying the data items for the OASIS assessment. (I am in home care) The flier is titled, "So That's What That Means!" and has a clip art mascot. The single sheet is sent to all six of my offices where the managers distribute it to the staff. I have gotten good feedback from the staff.....and have even been called regarding where it is if it happens to be a day late getting out! I have also done similar fliers for other topics, such as policies, infection control issues (washing hands , etc.) procedures. It gets the message to many this way and can be read on the job....or at home. Staff have asked me to do a flier on other topics they felt they wanted more information on. Anything that peaks their interest I find is worth it.

Being a well seasoned......or as my colleagues would call me, ancient, home care nurse, I agree with the above quote.....but only to a point. As a new nurse, you will find yourself working autonomously......and with some very sick people. All the "book" learning in the world can't prepare you adequately for what you will encounter in the home. It is not uncommon to be trying to instruct a 90 year old husband in taking care of his 88 year old spouse only to find that he is in worse shape than she is. The home care nurse must have exceptional assessment skills and observation skills as well as good old fashion common sense. There are those times when one walks into a home and must make a split second decision regarding the patient. There are no colleagues you can call to down the hall to give you an opinion......and trying to reach an MD via telephone could take hours. It may not be the blood pressure....temperature....or those measureable things that tell you something isn't right. It is pure gut instinct.....and the putting together of the assessment that validates your decision. The nurses that work in an an acute care setting prior to coming to home care will have garnered those skills needed to form a firm foundation to begin their home care experience. Of course you will grow and continue to learn.....we all do.....even this antique nurse. My role now is focused on the orientation, and mentoring of new nurses to the agency. Those that do well.....and enjoy their experience are those who began with a strong foundation in an acute care setting. Good luck!

Our agency uses the Protime 3. It is approved by the FDA and has literature to support its accuracy. I am one who does not always take things at face value and have compared venipuncture results with the Protime results and found them to be right on target. This machine uses a slide called a curvette.....and the blood is gathered from a fingerstick with a tenderlet. The curvettes can remain stored in a cool, dry place for up to 6 months. They do not need to be refrigerated......although I do advise the staff to not leave the machine in their cars overnight with the winter temperatures. This machine cannot be used for patients on Lovenox. It is primarily used for those patients who have poor venous access.....although many of the MDs are requesting the machine be used so they can get immediate results. The agency absorbs the cost for the procedure....which is about $6.00 a draw......but have found it to be worthwhile. We get accurate results, our homebound patients are not incurring costs for a lab to draw the specimen and those that are difficult sticks are not traumatized.

Thanks for the info. Both of the recommended sites are great!! My staff will be so pleased.:yelclap:

The form Kyasi is using is the standard CMS form. Our agency has this form as a part of a software program, so typing up the 485 is a matter of filling in the blank. (I can remember the days Florence and I were out there working and all 485s were handwritten ) Just remember when composing a 485 that the information is patient specific. Stay away from what is termed those "canned" statements. Those are the ones used for every patient no matter what the diagnosis or needs.

I gave found the RN Pocket Guide, WebMD, and the Merck Manual all quite helpful when I downloaded them to my iPhone. I am a perfectionist so I also made sure I downloaded Dictionary.

Our nurses must have bags that are washable or of a material that can be washed down. They must have a barrier between the bag and what object the bag is being placed on. This barrier can be something as simple as paper towel. The nurse must wash their hands prior to taking anything from their bag....and prior to putting anything back into the bag. Any equipment is to be wiped down with alcohol or disinfectant swab....or may be sprayed with a disinfectant such as Lysol. (Our State Surveyor was impressed when she saw this procedure being done!)

Best of luck to you in your new venture. You will be missed on this site....so I am pleased to see you will pop in every now and then. I enjoyed reading your posts and have learned much from you. I have just one request......save a padded room for me will you? Some days I think I could use one! Especially with all the changes with Medicare.

That looks like quite a comprehensive orientation. Very good! I am assuming that within your four day nursing orientation they will discuss Medicare guidelines, documentation, patient assessment, cultural diversities, safety etc. Good luck on your new venture!

Our agency policy is all paperwork must be turned in within 48 hours. It is true that the OASIS guidelines states the clinician must complete the OASIS data within five days of the SOC date, however, with the new PPS an agency would be nuts waiting five or more days for paperwork before being able to drop their RAP. As a result of the in-services conducted regarding this, they are turning their OASIS paperwork into the offices within 24 hours in a majority of the cases. I agree with KAZZ32......I would have a an Administrator pulling her hair out if we took five days to turn in the paperwork. :smackingf

Our PTA's are an invaluable resource for us. They work directly with the PT in providing hands on care to our patients. The PT develops the plan of care and oversees the progress the patient is making. This oversight is conducted through conferencing with the PTA, review of the medical record and visits to the patient. Having a PTA following the patient for the followup visits frees our PT so that he/she can open new cases. We find it to be a win-win situation.

oh my gosh! your type of orientation brings back memories of my own orientation to home care.....and that was 27 years ago! there was no oasis....no hhabn notices.....no pps. 485's were hand written. it was tough then coming into home care and not having a clue, (having had a background in maternal child heath and being requested to see medicare patients.) i received no orientation other than "ask any questions if you get stuck." there was no preceptor.....no mentor. i am not sure how i got through it then, but am glad i did for i love home care. now i am the educator for my agency and have developed an orientation program which is individualized for the new employee. the program is a combination of classroom and field experiences, precepting with a seasoned home care nurse, regular meetings with the supervisor, etc. they are not "set loose" to see patients on their own until they have completed the entire process and it is mutually agreed the employee is ready. this process takes eight weeks minimally. if one wants to have a successful employee, there must be some time and energy put into the process to assure it happens. i agree with the others who have responded thus far.......talk to the director. take it slow. just keep in mind that you are working with a license that you have worked hard to get. don't allow yourself to be pushed into something you are not properly trained for. take baby steps first....then run the marathon when you are ready. the best of luck to you.

I have completed orienting staff to the new case mix model, and focused on the two OASIS questions (M0110 and M0826). My agency has looked at setting up our system to do what some of the other writers here are going to do.......get the therapists out to the patient as early as possible. I have made our physical therapists, who are already stretched, aware that they will need to pass more of their follow-up visits to the PTA so that cases can be evaluated expeditiously. Likewise, any other therapies would be scheduled on the heels of each other. We had thought about a grid format, but because the care must be individualized and there are so many other factors that play into it, we think the timing of the evaluation is going to be the best way to obtain the needed information. Once an evaluation is completed, the therapist telephones from the patient's house to conference the case with the Supervisor. It is at this time the number of therapy visits is determined. I think all of us shall be sitting with bated breath waiting to see how it all works out. :uhoh21: