Delegate carefully: JCAHO checks aide tasks vs. law

Checklists ensure compliance, improve care

You’ve probably heard the jaunty ballad "The Yellow Rose of Texas," but home health agencies trying to comply with state regulations regarding RN delegation may instead be singing a bluesy tune lamenting the Grey Laws of Texas.

Like most state regulations on which tasks nurses can assign to home health aides, Texas’ laws "have some cut-and-dried answers for you, but there’s a lot of grey behind them," says Martha A. George, president and owner of Nashville, TN-based Healthcare Accreditation Consultants.

George helped Sherman, TX-based Avalon Home Health prepare for its first Joint Commis sion survey in May 1997. When the surveyor flagged a discrepancy between what the agency allowed an aide to do and state law, George jumped in to help keep the agency from losing its licensure.

Texas state law prohibits administration of medication by any aides not certified to give medications, and specifically prohibits aides from pre-filling "medication minders" — small plastic boxes that hold pills in compartments lettered with the days of the week.

After much investigation, including querying the state board of nurse examiners, the agency was able to prove that aides were allowed to pre-fill the med minders for patients who were "stable and predictable," though the law does not say this specifically, George says.

The agency prevailed and was awarded accreditation with commendation and deemed status for Medicare. But Terry Griffin, LVN, performance improvement director for Avalon, was concerned. So she asked George to create a system for tracking delegated tasks and flagging questionable items. The simple system flags delegation problems and serves to monitor patient care and bring areas needing quality improvement projects to light. The system also has greatly improved visiting staff’s knowledge of state law and Medicare requirements, Griffin says.

Such a system would be useful to quality managers in any state who wish to make sure they don’t run afoul of regulations and standards from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations.

To implement such a system, follow these steps:

Ask, "What are you doing?"

It’s a simple question that needs to be asked. George and Griffin talked with all the agency’s 10 aides to find out what tasks they were currently performing in the field. "We wanted to nip any immediate problems in the bud, " George says. Though they didn’t find any urgent problems, they did discover that the aides’ level of comprehension was not as high as the agency wanted it to be.

Ask the patient.

Nurses are out in the field every 14 days for the required aide supervisory visit. They began asking the patients what tasks the aides performed for them, as well as asking the aides what tasks they performed for that particular patient.

Create assessment forms to track tasks.

George created two separate assessment checklists: one for the RNs to check which tasks they delegate to aides during case conferences, and one for the aides to check the tasks that they have been assigned. (See sample assessment checklists, inserted in this issue.)

Decide what can be delegated.

The agency director and the director of nursing created a list of tasks that, according to state law and advice from the state board of nurse examiners, can be delegated to aides. The Internet also is a good resource, George says. (See George’s list of Internet resources, p. 105.)

Enter it all into a database.

Griffin enters the information received during the supervisory visit from the patient and the aide on site, and the information received from the two task assessment checklists, into a simple database that George created using a spreadsheet in Microsoft Excel. The list of tasks that may be delegated also is in the database. The program flags any tasks that have been delegated that are questionable, and they are investigated.

Trend and analyze data.

The system also helps improve the agency’s effectiveness of therapy and helps ensure continuity of care. For example, initial data suggested an unreasonably high incidence of nail clipper injuries last quarter. Training on foot care has "all but eliminated the problem," George says.

Re-educate staff based on data.

"When we notice a trend through this program, we do inservices and then skills tests that the RN supervises, and all this is included in the aides’ files," George says. This documentation help proves staff competency per Joint Commission requirements. Other than educating aides on when and when not to fill patient’s med minders for them, George and Griffin found another potential delegation problem that was easily solved. "Antibiotic ointment is a medication," says Griffin, "and if applied to a wound, the aide is actually administering a medication." A quick dressing change inservice increased staff’s understanding.

Don’t point fingers.

Data are anonymously aggregated and only raw data are used. "If you start finger-pointing from data, people stop participating" and stop helping you get the data, George says. Nurses have bought into the system because they can use the data to see at a glance what their aides are doing. That makes it easier to manage them, George says.

"They realize that ultimately it is their responsibility to supervise these aides, and they need to be aware of every task they are doing in the home," Griffin says.