It's 12 o'clock; do you know where your aides are? Supervision is key

Agency develops quality indicator to help nurses keep track

Nurses at Bennington (VT) Area Home Health Agency were a little slack in providing biweekly supervision to home health aides. So the agency established a quality indicator that nurses must supervise aides at least once every two weeks to meet a Medicare requirement, says Julia Maroney, RN, CDE, performance improvement supervisor of the freestanding agency that is affiliated with Putnam Health Corp., also in Bennington. The agency makes about 45,000 to 50,000 visits a year.

"We did a record review, and we found our compliance was simply atrocious," Maroney recalls. "We found that our staff didn't understand that they had to [supervise aides] all the time, and it was a serious violation not to [supervise them]."

Bennington Area Home Health supervisors worked on the problem for two years, bringing the agency's compliance rate for aide supervision up about 10% to 100%, Maroney says.

Here are the steps the agency took to successfully reach that goal:

1. Identify problem.

About four years ago, the agency had its first survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. This was the first time the agency created quality indicators. It was the accreditation process that brought the problem with aide supervision to light, Maroney says.

All of Bennington Area Home Health Agency's nurses are in charge of supervision of any aides seeing one of their patients, Maroney says. "Some agencies have one nurse who goes out and does the supervision, but that's not cost-effective because that's not a reimbursable visit," Maroney adds. "So our nurses try to combine this supervision with skilled visits whenever they can."

2. Educate staff.

The agency held staff meetings and went over the supervision requirement.

"Education was continuous and ongoing," Maroney says. "What you find is staff have so many rules and regulations to follow that they need to be reminded about what is important and what they must do without fail."

Nurses are told they must provide supervision at least once every two weeks. In addition, at least once in 62 days the nurse must be in the home at the same time as the aide to observe the aide performing duties, Maroney says. All this supervision needs to be documented, she adds.

The agency's problem with supervision persisted even after staff were educated. Managers took a look at which individuals were not following the rules. Those employees were educated again and warned there would be disciplinary action taken if they failed to comply.

"If we don't do our aide supervision, we're in violation of the Conditions of Participation and could lose our Medicare certification, and if we lose that we won't have jobs," Maroney says. "We had to make the importance of this supervision and documentation clear to the nurses."

3. Use supervisory flowsheet.

The agency uses a 23-item flowsheet that has boxes for the nurse to check whether an aide performed a task as ordered and whether the supervision was direct or indirect. (See aide supervisory flowsheet, inserted in this issue.)

Direct supervision means the aide is in the home, giving care to the patient while the nurse is there. Indirect supervision means the nurse is in the patient's home and the aide doesn't have to be present.

The nurse can provide indirect supervision during a regular nursing visit to the patient, Maroney says. The nurse will ask the patient two specific questions:

· Is the patient pleased with the service?

· Does the patient continue to need the service?

These questions need to be asked when the nurse is alone with the patient, because a patient often is reluctant to complain in front of the aide, Maroney adds.

4. Create an aide referral/care plan.

Nurses fill out an aide care plan that provides clear instructions about exactly what an aide is expected to do for a particular patient. Maroney says staff had difficulty filling out the agency's previous referral care plan correctly, so aides didn't know what they should do in patients' homes.

The new care plan, which is two pages long, makes these instructions very clear. (See aide referral/care plan, pp. 115-116.) Under the category of dressing, for example, the plan offers choices of the following:

· assist/dress upper body;

· assist/dress lower body;

· other (specify);

· orders for frequency if different from visit frequency;

· patient/caregiver special requests.

"This one has helped because now it's very clear what the aide is supposed to be doing in a particular patient's home," Maroney says. "Things won't get missed."

When nurses supervise aides, they may refer to the care plan to make sure that whatever is marked is being done by the aides. "It's important for the aides to have clear direction of what to do with their patients," Maroney adds.