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Hospice   (341 Views 5 Comments)
by 1jazzynurse 1jazzynurse (Member)

1,183 Profile Views; 17 Posts

Hi! I'm just trying to see something here. Has any of you ever case managed 30 home hospice patients with 4 LPNs? And if you do, how often are you required to perform a visit? If you do a visit, do you perform a full visit (full head to toe assessment).

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136 Posts; 1,730 Profile Views

I managed 24 with 3 LPNs.  It was a temporary situation (lasted about 2 months) while new staff were recruited and onboarded.  RN case manager mandated to visit Q 2 weeks for the supervisory.  Obviously, new admissions, transition patients, uncontrolled symptoms, etc. required more frequent in person assessments and adjustments to medications and plan of care.

That supervisory visit required a total assessment and I was prepared to spend a lot of time in the home.  I had to check everything for myself.  The LPNs were great nurses, but, there are responsibilities beyond LPN scope.

Great communication was key.  Not withstanding, some things fell through the cracks.  I would not recommend it long term.  I was exhausted, my team was exhausted and I am glad it is over.

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17 Posts; 1,183 Profile Views

Thank you. I am exhausted, things are slipping through the cracks, and i dont want to get in trouble for it. I was told not to do assessments, only ask about satisfaction with care! I have voiced my disagreements with this and was told that I am wrong and I am the reason why i'm overwhelmed! I am awaiting my state board to respond back to me so that i can give my employer proof in black and white. I was unable to find specifics in thr federal regs and thats what shes using as her rationale.

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136 Posts; 1,730 Profile Views

You are absolutely correct.  You are held to RN standards when looking at that patient in front of you.  If something is wrong, and you miss it because you did not do the assessment, how well do you think saying "The LPN didn't mention it" will go.  You are responsible for the actions (and inactions) of your team.  

The lack of support from your employer is a huge problem.  It is your clinical judgement that is expected - otherwise, why bother with an RN supervisory at all?  Why does the employer think RN supervisories are mandated?  

Run girl - run.

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332 Posts; 7,257 Profile Views

On 7/20/2019 at 2:43 PM, 1jazzynurse said:

Thank you. I am exhausted, things are slipping through the cracks, and i dont want to get in trouble for it. I was told not to do assessments, only ask about satisfaction with care! I have voiced my disagreements with this and was told that I am wrong and I am the reason why i'm overwhelmed! I am awaiting my state board to respond back to me so that i can give my employer proof in black and white. I was unable to find specifics in the federal regs and that's what shes using as her rationale.

Your state board isn't likely to weigh in on the standard of care for a hospice patient. It's Medicare that writes the standard, or the conditions of participation. Your agency does NOT meet the standard at all to simply ask about satisfaction.  Here's the specific wording (COPs link at the bottom):

Hospices are required to update the comprehensive assessment as frequently as the condition of the patient requires, which may be more frequently than every 15 days. The hospice must ensure that each update is completed no later than 15 days from the previous one. Hospices are not required to complete, in full, those documents that they identified as comprising their comprehensive assessment every 15 days, although hospices are free to do so if they so choose. They are required to identify and document if there were no changes in the patient/family condition or needs.

As you can see, the reg says the comprehensive assessment must be updated no less frequently than every 15 days, though not necessarily completely redone. Additionally, the IDT must meet no less frequently than every two weeks and determine if the patients needs are being met as outlined by the services specified in the plan of care:

Standard: Review of the plan of care. The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care.

If the nurse doesn't assess the patient, how can it be determined whether the needs are being met? How can progress toward goals be determined? Let's say the patient has wounds. If there's no assessment done, how can it be determined if it's healing, staying the same or getting worse? When they have a Medicare survey these will represent significant deficiencies, but that will be against the agency, not you.  With that said, your agency could well throw you under the bus, but it still would have fallen to them to supervise you appropriately;ty. However, anyone can report a nurse to the state board, and anyone can sue if things go Dixie. But prevailing against a nurse is a whole 'nother matter.

But bottom line, you know in your heart this isn't right, that it's not good care. If you can't get the powers that be to see that, you may want to move on.
https://www.govinfo.gov/content/pkg/CFR-2017-title42-vol3/xml/CFR-2017-title42-vol3-part418.xml#seqnum418.62

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