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
The Arena Changes
Home Care Facility Care
Bathroom
Dirty Utility room
Kitchen
Clean utility room
CSR: Central Supply Room
DME: Durable Medical
24 hour in house pharmacy
Equipment
Code Team/ ICU
Elevators
Local pharmacy
In house therapist
( PT/OT/Speech & gym)
911/you/ambulance
Whole Nursing Team
IV Team
Steps Respiratory Therapy Team 24/7
Visiting therapists
Home Health Nurse

3. The Home Care Nurse Nurse
Case Supply
Manager Acquisition
Transportation
coordination
Appointments Bathing, ADL, Personal
& School Care
Nutritional
Needs

4. Home Health Care
Arena
Advocacy Physician Home School Travel
Nursing Am care Feeds Wound care
Medications GT/ oral TUBE CARE
Care ADL/ OOB Ostomy /Foley
Transfers administration
Clean Supplies and
Supplies Physician orders for Procurement Acquisitions Equipment
everything
Administer Reorder/ restock Call MD for reorders Call Pharmacy as
Medication Reconcile Pharmacy Pick up needed.
Pick up meds PRN
Communication Letters of medical Schedule
Relay for the family Verbal Orders necessity appointments
Physician and MD Written transcribed and Prescriptions Arrange
signed off.
Transport

5. 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.

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 Responsibilities
READ IT~ LEARN IT~ FOLLOW IT
READ 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

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 Spinal Fluid
Cerebral
Record all Fluids/Solids/Nutrition/Excretions/secretions Entering/Leaving the body
Blood/Bile
Intake: anything that enters the body
Mucus/Saliva Anything that leaves the body
Output:
Emesis/Vomit
Oral solids or liquids Chest Tube
Formulas
Intravenous GT residuals
Parental Nutrition
Flushes Purulent drainage
Irrigations
Enemas
Wound drainage
Wound Vacuums
Hemovac/ Jackson Pratt
+/= Add up all Intake and output at
end of shift
Urine/Urostomy

12. Documentation
“ no/no” list
“ 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 ORDERS
what the skilled nurse should know?
what 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. Ethics
“THE UNWRITTEN RULES OF LIFE THAT KEEP BALANCE “
LIVE BY THE RULES....
eth⋅ics
[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

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 Diversity
RESPECT~UNDERSTANDING ~ EDUCATION
RESPECT~UNDERSTANDING ~ 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
ACCEPT~UNDERSTAND~REACH OUT

19. 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 Equipment
“DME”
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, Trach’s, 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,
AFO’s, 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 comp’d on the case prior to or on first shift.(Skills Lab & in home)
• Do not take a wellness clinic with out Comp’s : 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
Reassessments:
Change in status Change in status
Falls/Incidents
Day 56-60 by RN or CS
Every 56-60 days for Post Hospitalization
Discharge
ROC (recertification of
services)
Post Hospitalization
Discharge

30. Supervisor Check LIst:
Assess Patient Vital
signs/pain/ Diagnosis Chart/POC in order and organized
pertinent & changes noted
Review 485/POC with family/staff
Assess nurse performance/
procedures and treatments Case conference/Cases management
and level of skill occuring
Medication POC current for Certification period
Reconciliation/storage/expira
tion dates Goals Addressed/updated
Patient MD DME organized and Clean
appointments/updates
OSHA maintained: hand washing
Patient Education/response
Safety needs
Client/Family Satisfaction
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 Track,
Investigate,
Client falls
Evaluate, Analyze,
Employee injuries 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
provided;metrics 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