Orientation to Home Care 101 - PowerPoint PPT Presentation

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Orientation to Home Care 101

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Title: Orientation to Home Care 101


1
Orientation to Homecare 101
  • Home Care Series by
  • Tammy Marie Baker RN

2
Home Care vs Facility Care The Arena Changes
Facility Care
  • Bathroom
  • Kitchen
  • DME Durable Medical Equipment
  • Local pharmacy
  • 911/you/ambulance
  • Steps
  • Visiting therapists
  • Home Health Nurse

Home Care
Dirty Utility room Clean utility room CSR
Central Supply Room 24 hour in house
pharmacy Code Team/ ICU Elevators In house
therapist ( PT/OT/Speech gym) Whole Nursing
Team IV Team Respiratory Therapy Team 24/7
3
The Home Care Nurse Nurse
Transportation coordination Appointments School
Bathing, ADL, Personal Care
4
Home Health Care Arena
Advocacy Physician Home School Travel
Nursing Care Am care ADL/ OOB Transfers Medications administration Feeds GT/ oral Wound care TUBE CARE Ostomy /Foley
Supplies Physician orders for everything Procurement Acquisitions Clean Supplies and Equipment
Medication Administer Reconcile Reorder/ restock Call MD for reorders Pharmacy Pick up Call Pharmacy as needed. Pick up meds PRN
Physician Communication Relay for the family and MD Verbal Orders Written transcribed and signed off. Letters of medical necessity Prescriptions Schedule appointments Arrange Transport
5
Everything Requires a Physician Order
  • Home Care Physician orders are the signed 485 POC
  • 485 is signed by DOCS and MD
  • 485 POC is updated / re certified every 60 days
  • All treatments and Medications must have a
    physician order
  • Supplies require MD Prescription for
    Reimbursement
  • Supplies may also require a letter of medical
    necessity with Rx
  • The homecare Nurse is instrumental in helping the
    family get supplies through communicating with
    the Physician
  • The Home Care care nurse assesses the clients
    needs and relays them to the Physician. You are
    the one with the client on a daily basis.
  • Assessment and Communication are Essential

6
485 THE PLAN OF CARE
  • THE 485 IS THE PLAN OF CARE
  • IT IS THE PHYSICIANS ORDERS FOR THE HOME CARE
    CLIENT
  • IT DESIGNATES DIAGNOSIS CODES ASSESSMENT
    PARAMETERS TREATMENTS MEDICATIONS DME
    EQUIPMENT ALL WRITTEN ORDERS
  • IT IS REVIEWED AND UPDATED EVERY 60 DAYS (STATE
    REQUIREMENT)
  • THE PATIENT IS REASSESSED BY AN RN AND A VERBAL
    REPORT IS CALLED TO THE MD POST ASSESSMENT
  • A VSOC IS OBTAINED AFTER MD IS GIVEN
    UPDATES/SPOKEN TO
  • IT MUST BE IN THE CLIENTS HOME CHART and CURRENT
    DATES EVIDENT FOR STATE COMPLIANCE

7
Physicians Orders
  • Physician must be notified of changes in clients
    status. You call the Doctor and document the
    communication.
  • Verbal orders are taken, written, signed off, and
    communicated back to the DOCS at Maxim Office
    within 24 hours by the Home Care Nurse.
  • All orders from a Physician must be brought to
    the Maxim office to be entered into the clients
    MARS and 485 POC by the DOCS.
  • If the orders are received in physicians office
    have them faxed directly to our office for speed
    and accuracy.
  • Maxim Home Care Chart and Office chart must be
    kept up to date for Coordination of Care ,
    Accuracy, and Compliance.
  • Call your DOCS with ALL NEW ORDERS.
  • Original orders come back to the office with
    Nurses notes
  • Yellow back up stays on the home chart. The home
    Chart and the Office Chart should both have the
    same and current information and orders.

8
485 The Nurses ResponsibilitiesREAD IT LEARN
IT FOLLOW IT
  • The Nurse or HHA is responsible for knowing their
    clients POC
  • The nurse should document according to the goals
    and treatments on the POC
  • Education is geared to Goals and POC oriented
  • Goals are reviewed and revised and accurate to
    meet patient needs

9
Documentation
  • It must be legible to be legal and follow Maxim
    Policy and Procedure.
  • All nurses notes are to be signed by the nurse
    legibly with your
  • Full legal signature Nursing credentials.
  • Sign those initials. You earned them. Be proud of
    them- LPN/RN/CHHA
  • Documentation must be accurate, objective,
    precise, and timely.
  • All nurses notes must be signed by the patient or
    family member.
  • This is proof of the nurses care and presence.
    Exceptions must be assessed by the DOCS.
  • It is not Legal or Ethical to sign a clients or
    family members signature
  • It constitutes Fraud and is a Felony
  • Please read your notes and check them before you
    have family sign on them
  • Please double check time in/ time out and dates
    double check them!
  • White copies are turned into office weekly /
    yellow carbon copies remain on the chart
  • The NO no List
  • DO not use white out. Do Not Cross out or
    scribble. DO not write error
  • Transcription of number ( tracing over to change
    a number is not allowed)

10
PDN FLOW SHEET
  • Time in___time out____ circle( AM/PM) the time
    you started and check date by calendar
  • Document full Vital Signs at least once per shift
    and per MD orders
  • Check all appropriate boxes per system.
  • Pain is the 5th vital sign document it
  • Education Related to goals /Diagnosis/Medications
    /discharge planning
  • Called MD? document call/time and why
  • Narrative summation of Shift. Subjective (
    factual events and patients tolerance of
    care/activities/procedures.)
  • How Received in care of__________ and left in
    care of ___________
  • Review your own documentation prior to signing
    and submission for accuracy and error be
    proactive
  • notes are written on shift not before or after

11
Intake/Output
  • Record all Fluids/Solids/Nutrition/Excretions/secr
    etions Entering/Leaving the body

Cerebral Spinal Fluid Blood/Bile Mucus/Saliva Eme
sis/Vomit Chest Tube GT residuals Purulent
drainage Wound drainage Wound Vacuums Hemovac/
Jackson Pratt Urine/Urostomy Stool
rectal/colostomy
Output Anything that leaves the body
  • Intake anything that enters the body

Oral solids or liquids Formulas Intravenous Parent
al Nutrition Flushes Irrigations Enemas
/ Add up all Intake and output at end of shift
12
Documentation no/no list
The NO no List DO not use white out. Do Not
Cross out or scribble. DO not write error NO
Transcription of numbers or letter ( tracing
over to change a number is not allowed)
X
X
X
X
error
strode
k
13
MEDICATION RECONCILIATION
Patients medications are reviewed daily by
PDN Medications must have 5 rights 1-Right
patient ( whose prescription is it?) IDENTIFY THE
PATIENT 2-Drug Name 3-Dose with concentration
noted 4-Route 5-Time ( prn must specify the
reason pt is on med, re headache, pain , fever
ect?) ( concentration ) How many (___mg/ ___ml )
we must have this on every medication Example
Tylenol ( 325mg/tab ) give 650 mg by mouth bid
New medications must have MD orders Medication
changes must be reported to Clinical Supervisor
or DOCS Medication profile and Mars must be
accurate and reflect all current meds ALL MEDS
ARE SIGNED OFF ON MARS FULL SIGNATURE AND
INITIALS AT BOTTOM OF MARS MEDS NOT GIVEN? CIRCLE
YOUR INITIALS AND DOCUMENT WHY Med storage in
home patients meds must be stored in a safe
place and segregated from other family members
meds. Medication expiration dates should be
checked. Proper disposal of expired meds and pt
education is necessary Narcotics require a
narcotics count sheet and need to be counted
daily Sharps precautions for needles. ( sharps
boxes are available at local pharmacy)
14
Transcribing medication ORDERSwhat the skilled
nurse should know?
  • HOW TO WRITE A MEDICATION ORDER
  • PROPER FORMAT (CONCENTRATION) HOW MANY (
    __MG/___ML ) we must have this on every
    medication
  • DO NOT USE CC
  • DOSAGE ORDERED HOW MUCH
  • FREQUENCY /DURATION
  • PRN INDICATIONS SPECIFY THE REASON DRUG IS TO
    BE GIVEN IE HEADACHE/ FEVER/ PAIN/CONGESTION
    ECT....
  • OXYGEN IS A MEDICATION IT MUST BE LISTED ON MED
    PROFILE
  • Example
  • Tylenol ( 325mg/tab ) give 650 mg by mouth bid
  • New medications must have MD orders
  • Medication changes must be reported to Clinical
    Supervisor or DOCS
  • Medication profile and Mars must be accurate and
    reflect all current meds

15
MEDICATION CHARTING
  • MED PROFILE ON EACH CHART FROM ADMISSION, UPDATED
    PRN AND AT RE -CERTIFICATIONS SIGNED BY NURSE AT
    SUPERVISIONS EVERY 30 DAYS NEW PROFILES NEEDED
    WHEN MEDS CHANGE
  • ADMISSION MED PROFILE REQUIRES DATES OFF
    PRESCRIPTION BOTTLES NOT DATE OF ADMISSION
  • MED PROFILE REQUIRES MED CLASSIFICATIONS FOR EACH
    MED
  • MED PROFILE SIGNED OFF DAILY BY RN INITIALS IN
    BOXES ONLY IF GIVEN
  • DO NOT SIGN OUT MEDS GIVEN BY FAMILY ( NOT LEGAL)
  • DO NOT SIGN OUT MEDS GIVEN BY ANYONE OTHER THAN
    YOUR SELF.
  • FAMILY DOES NOT SIGN MARS
  • NURSE MUST DATE/TIME/INITIAL IN BOX FOR EACH MED
    GIVE
  • RECONCILIATION SIGN THE MEDS MATCH THE MD ORDERS
    WHEN NEW MARS RECEIVED
  • MED ADMINISTRATIONS SHEETS COME BACK TO OFFICE
    WHEN COMPLETED AT END OF WEEK.

16
EthicsTHE UNWRITTEN RULES OF LIFE THAT KEEP
BALANCE LIVE BY THE RULES....
  • ethics
  • eth-iks
  • plural noun
  • 1.(used with a singular or plural verb ) a system
    of moral principles the ethics of a culture.
  • 2.the rules of conduct recognized in respect to
    a particular class of human actions or a
    particular group, culture, etc. medical ethics
    Christian ethics.
  • 3.moral principles, as of an individual His
    ethics forbade betrayal of a confidence.
  • 4.(usually used with a singular verb ) that
    branch of philosophy dealing with values relating
    to human conduct, with respect to the rightness
    and wrongness of certain actions and to the
    goodness and badness of the motives and ends of
    such actions.
  • ETHICS ARE AN INTEGRAL AND IMPERATIVE COMPONENT
    IN NURSING
  • ETHICS ARE NON NEGOTIABLE
  • ETHICS GO HAND IN HAND WITH COMPLIANCE
  • AND QUALITY OF CARE

17
Client Relationship Boundaries
  • You are a guest and a caregiver in the clients
    home
  • Respect the client and families personal space.
  • Allow the family their Privacy
  • Do not interfere with in family personal
    business Stay out of family quarrels and
    finances
  • Respect bath room privacy knock or state is
    anyone in there before entering
  • Refrain from eating the clients food
  • Request permission to use kitchen, microwave of
    refrigerator
  • Respect cultural boundaries and customs.
  • Maintain a professional relationship

18
Cultural DiversityRESPECTUNDERSTANDING
EDUCATION
  • Cultural Diversity must be observed at all times.
  • Not all cultures practice their beliefs, do not
    assume observe
  • Education on the particulars of the families
    cultural and religious beliefs is essential
  • If your not familiar with the families culture
    ask your supervisor or Director for help
  • Different cultures speak different languages
    dress differently eat different foods, view
    medical needs differently experience pain and
    needs differently as nurses
  • Different cultures are offended by gestures, eye
    contact showing of skin clothing
  • hand shaking etc
  • ACCEPTUNDERSTANDREACH OUT

19
SAFETY IN THE HOMEWe are the Safety police
Assess the home upon admission and routinely for
Safety Factors, problems and needs
  • Assess the clients home for Safety issues.
  • Body Mechanics for client and Staff
  • Is the clients bed safe is it a good height for
    the client and nurse
  • Bathroom safety Bars , commode lifer, non slip
    surface mats
  • Kitchen Safety safe stove , pot handles in,
    burners working
  • Are extension cords safe or a fire hazard (
    frayed, worn, over loaded)
  • Does the client have a working phone
  • Does the client have electric and running water
  • Are smoke and fire distinguishers present
  • Are the medications stored separately, with in
    dates and not expired, out of reach of small
    children and elderly
  • Are floors clear of clutter, throw rugs to
    prevent falls and tripping accidents
  • Lifting safety? Is the client able to walk,
    transfer or do they require a lift.
  • Ramps and house access for disabled
  • Abuse Risk assessments elderly, small children
    and disabled

20
Pediatrics/Child Proof?
  • Electrical plug covers
  • Stove handle covers, pot handles inward
  • Medicine safety lids and out of reach
  • Poison control hot line present
  • Bed rails or crib rails, gates up
  • Tub safety, never leave unattended
  • Water temp checked prior to bath

21
Documentation Accountability
  • Nurses give report and get report
  • Please indicate who you picked up the client from
    and how you received report
  • Please document whom you left the client in care
    of .There is a box for this on the flow sheet at
    the bottom.
  • Family or client must sign flow sheet at the end
    of shift.
  • Samples
  • 1) Baby Billy was received in the care of mom.
    Mom States Baby Billy had a good day with O2 sats
    at 98.
  • 2) Jimmy Joe was received from Nurse Nancy.
    Verbal report given.
  • 3) Karen resting in bed, side rails up, no
    apparent distress noted.
  • 4) Suzie Q was left in care of Uncle Sam and
    resting comfortably in bed.

22
Durable Medical EquipmentDME
  • Your DME is your clients medical equipment
    supplier / What constitutes DME?
  • Examples Wheel chairs, Canes, Hospital beds,
    Hoyer lifts ,Medical strollers, Special Needs Car
    Seats, Standers, Shower Chairs, Ventilators,
    Trachs, Suctions Catheters, Nebulizer Machines,
    Pulse Oximeters, Coughalaters, Gloves, Gauze,
    Tape, Diapers, Tube Feed Supplies, GT Formula,
    Pumps, Feeding tubes, air mattress, ostomy
    supplies, Foleys, Shower bars, Commode Elevation
    Seats, Commodes, Tens Units , Orthotics Braces,
    AFOs, Body Jackets, Neck Supports, Wrist
    Splints, Swath, any type of orthotic brace.
  • A client may have more than one DME supplier?
  • Respiratory, Orthotics, Seating and Adaptive
    Equipment.
  • It is important to keep a list of suppliers and
    what they supply to the client.
  • All DME is prescribed by a MD. They will write a
    Rx and may add a a LOMN
  • ( letter of Medical Necessity) to acquire the
    position.

23
DME Cleaning
  • All equipment should be cleaned and maintained.
    Sanitation of equipment is done by wiping down
    equipment daily and then soaking equipment for 20
    minutes once a week in a
  • 10 solution of vinegar and water.
  • (1oz vinegar to 10 oz water)
  • Submerge items in solution for specified length
    of time 15-20 minutes twice week.
  • Remove disinfected items from basin and rinse
    in water.
  • Air dry or dry with paper towels before storing.
  • Store in clean, dry, dust-free environment,
    e.g., plastic, ziploc bag,
  • or lidded jar .
  • . Discard solutions into toilet, wash basin with
    soap and water,
  • rinse and dry with paper towels.

24
ON the Clients Home Chart
  • Current 485 present
  • HIPAA
  • Emergency Plan /Numbers
  • Advanced Directives
  • Falls Precautions
  • History and physical
  • Physicians Orders signed off and sent in to the
    office
  • Nurses notes
  • MARs Med Profile current

25
Emergency Plan and Numbers
  • Client must have an emergency plan for
    evacuation.
  • Client must have emergency numbers on chart.
  • Nurse must be able to safely evacuate client if
    needed.
  • Consideration mobility or lack of, equipment O2/
    vents, wheelchair ramps etc.
  • Know the county emergency numbers/ Disaster
    plan.
  • Power outage Flash light, batteries, generators
    and back up vent ready evacuate if no power and
    unsafe.
  • Keep back up equipment charged at all times for
    Emergacny

26
Death and Dying in the Home
  • Know patient code status, living will etc.
  • Respect family wishes
  • Full code- initiate CPR and call 911
  • If the DNR (signed by MD ) is NOT in writing, it
    is a FULL code no matter what the family wishes
    are.
  • NO CODE support and respect client
  • Post mortem care per family wishes
  • WHO TO NOTIFY
  • 911 Client Physician HHA Office, Direct
    Supervisor Director of Nursing.

27
NEW CASE MEMO
  • Do not take a case with out talking to the DOCS
    or your clinical supervisor
  • You must be given clinical report first from a
    clinician. Report maybe by phone in office or in
    person but must come from DOCS or CS ( A
    Clinician not a recruiter)
  • First case is oriented in the home on first shift
    with a Clinical Supervisor
  • Nurses must be compd on the case prior to or on
    first shift.(Skills Lab in home)
  • Do not take a wellness clinic with out Comps
    SEE THE DOCS FIRST
  • If you are asked to staff a case you must give a
    definite YES or NO
  • YES I will take the case or NO I can not.
  • All sick calls should be made at least 4 hours
    prior to shift.
  • Frequent call outs are not acceptable. Our
    clients are expecting a nurse for care and it is
    not professional to not show up, not call or not
    call out in an appropriate time manor. Remember
    that a sick client is counting on us to be there.

28
Supervision of Staff
  • HHA/RN/LPN follow State/Federal and Agency
    regulations and best practice initiatives
  • RN once per year/LPN Biannually/CHHA
  • First case supervision all levels of care
  • Client is supervised every 30 days
  • 90 Day appraisals/Annual Appraisals of staff
  • Annual Appraisel

29
Supervision of Client
  • Every 30 days
  • Change in status
  • Every 56-60 days for ROC (recertification of
    services)
  • Post Hospitalization
  • Discharge

Reassessments Change in status Falls/Incidents D
ay 56-60 by RN or CS Post Hospitalization Discharg
e
30
Supervisor Check LIst
  • Assess Patient Vital signs/pain/ Diagnosis
    pertinent changes noted
  • Assess nurse performance/ procedures and
    treatments and level of skill
  • Medication Reconciliation/storage/expiration
    dates
  • Patient MD appointments/updates
  • Patient Education/response
  • Client/Family Satisfaction
  • Chart/POC in order and organized
  • Review 485/POC with family/staff
  • Case conference/Cases management occuring
  • POC current for Certification period
  • Goals Addressed/updated
  • DME organized and Clean
  • OSHA maintained hand washing
  • Safety needs
  • Discharge Planning

31
Hospitalization
  • Notify family if not home.
  • Notify HHA office/ DOCS.
  • Notify Client Physician.
  • Notify Respiratory DME vendors, e.g. trach /
    vent, oxygen.
  • Documentation.
  • HHA ON CALL SYSTEM (24/7) ________________
  • 911

32
Performance Improvement
  • RISK Management
  • Grievance Logs
  • Incident Reporting
  • Accident/Injury reports
  • Workman's comp
  • Medication errors

33
Tracking Occurrences
  • Medication Errors
  • Decubiti/skin breakdown
  • Infections Wound, Respiratory, Urinary
  • Client falls
  • Employee injuries

Track, Investigate, Evaluate, Analyze, Write a
plan of Correction to Prevent and Improve
Outcomes
34
Quality Improvement
  • All nurses notes are Q/A weekly read and Signed
    by DOCS
  • All Charts are Q/A quarterly audited for
    protocols and errors
  • Errors are reviewed performance reports are
    written Education/Re-education is
    providedmetrics are reassessed within 30 days
    and reviewed
  • Errors and Incidents are learning tools for the
    future and utilized to improve future processes
  • Performance Improvement Plan developed/Implemented
    / Evaluated 30 days
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