Orientation to Home Care 101

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Orientation to Homecare 101

• Home Care Series by
• Tammy Marie Baker RN

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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
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The Home Care Nurse Nurse
Transportation coordination Appointments School
Bathing, ADL, Personal Care
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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
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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

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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

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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.

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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

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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)

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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

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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
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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
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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)
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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

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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.

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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

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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

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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

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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

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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

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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.

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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.

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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.

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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

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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

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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.

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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.

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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

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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
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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

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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

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Performance Improvement

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

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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
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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