Two part ? re mileage and HHA sup's

OK, part one. How do you calculate your mileage? Let's say you took your charts home the night before, and are starting out from home?

We all know no one gets paid to travel to work. One agency I know of said you would not get paid if you start from home, on the way to your first job, even if it was 50 miles. My present agency is unconcerned, and many nurses deduct the miles it would have taken them to get to the office from the actual miles. (exmaple, I have to go 14 miles to first visit, but it takes my 6 miles to get to office, so 14 - 6 = 8 miles I would count as mileage to that visit.)

However, I usually go in Friday 5 pm to get my sat charts, since I often have early visits since I work 12 hours, so any BID's would go to me. So, as far as I am concerned, on Sat am I should count all the miles to my first job since I was already to the office. Even though these miles may be more since my home may be firther away than the office would be.

Also, what if you have a gap in time, but rather than go to the office, you go home to do paperwork. I know many of you don't have the luxury of working in only one county close to home like me, but how would you count the miles to the next visit? Technically, my home is like my office, but officially, it's not a designated office. So, what I usually do is approximate the miles it would take from the previous visit to the next, since you should deuct personal mileage. What do you think??

Also, as a quick poll, do you count tenths of miles or round? I round. Do you do trip odometer? Or just all the miles in a day? My agency wants us to account for miles per vsits and time traveled per visit, but other agency only wanted daily miles and total travel time. How about you?

Part 2: HHA sup's. I am interested in your agency's policies. How often are you actually there when the HHA is? I don't know about you guys, but I would waste a whole lot of milegae trying to get to every HHA sup while the HHA is actually there. We used to have a policy that stated that at least once a month the sup had to be done while the HHA was in the home, but that seems to have fallen by the wayside, due to short staffing. My agency has been hiring many LPN's to replace lost RN's, and it is getting difficult to spread the RN's out to accomplish all the HHA sup's recerts, news discharges, etc... So, I was wondering, has anyone worked this out or have a specific policy?

Thanks.

I understand your questions regarding mileage. I worked for 2 HHAs in the past and this was the way mileage was done:

During the work week: starting the day out, home to office mileage was not counted. From office to first visit and all subsequent visits were counted and mileage count stopped at office at end of day.

For those work days during week when visits were started from the home and continued to past the closing of office for the day, (visit to office was not possible): All mileage was counted from point of first visit to last visit made. Mileage count then stopped.

On weekends the mileage started from first visit of day and ended when returned to home. (I felt this was a nice thing to do since it kinda sorta put a buck or two more in the paycheck).

Our mileage was rounded off to the next number if odometer stopped with .5 or over.

In my business we set mileage from time leaving home to time getting back. We average over 500 miles each week and so it is one of our biggest business deductions. It does give me a greater appreciation of the attention most HHAs give to the mileage it's nurses and aides rack up.

Just curious: what is your reimbursement per mile at your agency?

As for the aide supervision thing: too bad LPNs are not allowed to help you out in that area.

[hoolahan, ASN, RN]

Thanks Lois!

And you make a very interesting point. In NJ, LPN's are allowed to be in charge in LTC facilities, which includes supervising CNA's, so WHY NOT have LPN's supervise HHA's? They are certainly capable of doing that!!!

But, how do you do it? Must the HHA be present in the home? If so, for q sup, or once per month, or any disclaimers involved?

Yup, the question is a real poser isn't it?! As a charge nurse in LTCs for over 15 years of my 27 year practice as an LPN, you can imagine my angst over the idea that for some reason or another the job of supervising nurse's aides was somehow a 'no no' in the HHAs.

Here is the way it ought to be done--in my opinion: a home health aide needs to be visually observed once per month in a patient care setting. Any difficulties she may have or any questions she may have are addressed right then and there. If the LPN were to supervise the aide then a check list would be used and a description of the aide's abilities or disabilities would be written; the aide would know up front what is being written down. The form would be given to the Care Manager RN for her perusal and signature. The RN would be ultimately responsible for any necessary up-grading in patient care skills that the aide might need and/or utilize the LPN to do the necessary training. Let's say an aide was observed by the nurse and did a great job, but two weeks later an indwelling foley catheter is ordered up. The LPN would go back into the home with the aide and orient her in the care of the catheter add it to the check list. There's a lot more to this, but really it's quite simple if the LPN is incorported intellegently into the whole scheme of things.

Let me give you a scenario I see too often in my travels:

I often come into a home after an aide from another agency has provided care for the client. The aides who provide these cares are not certified; they have had NO orientation in even the simpliest form of assessment- i.e., noting and reporting areas of breakdown; hygienic care of the feet, hands or perineal areas; indwelling catheter bag care- and more that I'm not going to get into right now. I have asked these aides if their supervising nurse comes in on a regular basis to observe their work- the answer is, "No". I have asked if they ever recieve inservices at the agency they work for- the answer is "No"; I have asked them what kind of qualifications are required from them before they hire in and they tell me, "None".

Understand that my partner and I are not bound by any policy of our own to train another agency's aide in the basic ways of patient care, nor do we feel it is within the bounds of good faith to "step on the toes" of another agency. Both of us have called and questioned RN Care Managers regarding the non-trained personnel they have going into the homes and we always get the same answer: "That's the way it is".

We are in the homes on a once-a-month basis. Over the years we have had a total of 75 clients to date who presented with ulcerations of the feet which we staged at no less then III and IV!

Each of these clients were being seen to by non-trained, non-certified personal care assistants. Since they had no requirement to report to any nurse and since no nurse was observing them on a regular basis in the home the client's condition went unattended--until we came in on referral to see to their foot care needs...and then found more needs to boot! Our policy is to alert the physician first, the HHA second...we let the doc and the agency duke it out by themselves. Both of them knowing that our little business has the patient report in our files.

We have a distinct advantage point as self employed entities: we can stand back a bit and really see the mess that agency nurses face every day. We are fully aware of how over worked they are and how maddening it must be to KNOW that circumstances beyond their control make their duties to their patients almost impossible.

I say, if the hospital nurse thinks she's got it bad, let her try home care sometime! (Even tho I wouldn't trade it for the world). But....

one of the greatest blunders made in nursing today is the under-utilization of the LPN...(saddens me just to think about it). I would wager that any thinking RN could come up with at least a dozen skills that the LPN could do which would greatly reduce the pressure on the RN in any clinical setting. Aide supervision for starters.

Lois Jean

[NRSKarenRN, BSN, RN]

HiGuys:

Agree with LoisJean re mileage...how I've done it for the past 15 years.

RE home health aide supervision: the q 2 week supervisory rule is a MEDICARE condition of participation rule--supervisory visit is considered an administrative function and is non billable UNLESS skilled care is also rendered. Under SBON license rules RN is independent practioner; LPN is practices under MD/RN supervision only.

Most insurances/ office of aging programs follow MC rules for supervision.

Purpose of supervisory visit is:

1. Review plan of care with the aide and make changes if indicated.

2. Assure aide is following plan of care.

3. Teach care to aide.

Recognized standard is AT LEAST monthly eyeball visit with aide.

When I was Case managing here's how I made visits.

1. I identified with client/caregiver or agency assigned time for aide to visit then sheduled my visits with client during that time frame, especially for long term cases; that is I scheduled SNV around AIDES schedule.

2. If cases were short term or new, contacted HHA scheduler to see when aide assigned and confirmed info with client.

3. If sup visit due that week, called client 24-48hrs before visit date to confirm aides schedule not changed.

4. For recalcentat/unreliable aides, notified HHA supervisor/scheduler of time frame I expected to be at patients home AM of day BEFORE visit. They paged/contacted HHA with utimatum that I was visiting and they had better be there at the agency scheduled time.

5. MC requires HHA's have 14 hrs of continuing education/inservices yearly. I carried inservice forms with me and as part of sup visit would review a topic e.g. body mechanics, use transfer board/hoyer lift, emergency removal of bedbound client from home, hair and nail care etc. with credit for 1 hour given.

Most of the aides in my area would be available 90% time; some aides would even have me paged when their schedule changed so they wouldn't miss an inservice credit. Also did yearly OBRA visit on aides.

6. Combined as many skilled visits with sups as possible.

If couldn't meet with aide, reviewed with family that aide following POC.

7. Monthly cath change client---would visit day of week aide in home; opposite two weeks would try for visit, otherwise document TC sup with family...very simple check off form for this call.

Hope this helps.

Karen