Patient visits are where ‘the rubber meets the road’

JCAHO focus: Patient rights, staff competency

Neither Kay McRae, RN, CQI coordinator, nor Patricia R. Jones, RN, administrative director of home health, expected the Joint Commission surveyor to spend an entire day going on home visits when Memorial Home Care in Lufkin, TX, was surveyed recently under the 1997-1998 standards.

But she did. She even went to several of the agency’s branches and visited patients of the branches as well, paying special attention to the patients’ rights standards.

"She was really interested in [physical] restraints," says Jones, whose hospital-based agency received accreditation with commendation after the survey. "On all the bedfast patients, she would run her hands down the side of the rails to see if there was anything tied to them."

‘We give her one and it makes her rest’

She was equally attentive to chemical restraints. On every patient that had "any kind of a sleeping medication," the surveyor asked the family under what circumstances the medication was given. In one such instance involving Haldol that was originally prescribed for routine administration, a patient’s elderly sister replied, "We just give that to her when we can’t do anything with her. We give her one and it makes her rest."

"That makes it a chemical restraint," Jones says. The surveyor then checked the patient’s home chart to make sure that when the physician and the family agreed to change the order from "routine" to "as needed," home care had followed up with education on chemical restraints. Luckily, the nurse who took the new order did chemical restraint teaching with the family, left an educational handout on restraints, and documented what she did in the chart.

One year prior to the survey, the agency’s survey preparation committee discovered that its restraint policy called for staff to teach family members about alternatives to using restraints, but that the agency had no teaching materials that outlined what those alternatives were, McRae says. It was the educational tool that McRae created to fill this gap between policy and practice that the surveyor found in the patient’s home chart. (See patient/caregiver education tool on restraints, pp. 73-74.)

[Editor’s note: Memorial HomeCare’s restraint policy was derived from the one produced by the Texas Association for Home Care, which costs $8 for members and $16 for non-members. Call (800) 880-8893.]

During home visits, the surveyor also asked several questions of patients, including:

• Are the nurses respectful of your rights?

• Have you had any trouble contacting the agency after hours?

• Do you have the Texas Home Health Hotline phone number for reporting a problem to the state?

• What would you do if there was a flood or ice storm?

• Has there been a time when a nurse didn’t show up when she was supposed to, and did she call to say she was not coming?

• Have you called the agency for an emergency? How did staff respond?

• If you had a complaint, who exactly at the agency would you call?

"She wanted a name," Jones says. Upon admission, the agency gives patients a folder that includes a letter from Jones telling them she is the person to call if they have a complaint. The letter gives emergency phone numbers as well. Each patient keeps his or her folder in the home. However, as many patients had been on service for an extended period of time, Jones recommends that staff pull the materials out of the folder to refresh patients’ memories prior to the survey.

The surveyor praised the field staff, noting the rapport with patients that she observed during the home visits. "She told us that was where the rubber meets the road in home care," Jones says. The surveyor was especially pleased to observe that patient and family members were comfortable asking questions of staff, in spite of her presence.

The surveyor asked the following questions during interviews with staff:

• Summarize the patient’s course of care.

• Where is the patient in his or her certification period?

• What has the patient been taught? Where are you on your patient teaching plan?

However, she found fault with the way the agency was notifying patients in writing of the potential cost of home care prior to care being rendered, per standard RI 1.1.1. As managed care becomes more prevalent, many agencies face the dilemma of having to provide care prior to actually talking to a payer case manager about the policy’s coverage. Memorial HomeCare had adopted a procedure that called for notifying the patient in writing of what the agency predicted the plan would cover, but noting that they would have to wait until contact with the case manager to be sure. After discussion with the case manager, staff would call the patient with the updated coverage information, and then follow up with a letter the next day.

Follow-up note details actual coverage

The surveyor said the agency instead must provide to patients in writing the total cost of home care services that the patient would be required to pay, at full price, as if the patient’s policy paid for nothing. Then after contact with the case manager, a follow-up note needed to be sent to the patient with the actual coverage and cost to the patient.

In the area of staff competency, the surveyor gave the agency a supplemental recommendation and indicated that the agency needed to establish a process for using aggregate staff competency data through which trends could be detected and acted upon. Despite liking Memorial’s annual skills lab, which tests all clinical staff on all clinical skills, the surveyor did not find that the agency had tracked the scores of staff and then developed inservices based on the needs determined from those scores.

"She wanted to see that we had, at the end of some finite period of time — quarterly, mid-year, or annually — looked at all the tests that we had given everybody that year. If we found out 20% were not proficient in accessing a Port-a-Cath, for example, we therefore would have education opportunities on that," says Jones.

She also recommended that the agency pick four to six areas that all staff should be proficient in, "core competencies" based on the agency’s patient population, rather than try to have all staff be proficient at all skills, McRae says. But she was careful not to dictate what core competencies should be.

Address care planning problems

The surveyor’s final main focus was on care planning, and she gave a 60-minute inservice to the agency’s nurses on how to identify problems and follow up on them in the care planning process. "If you identify a problem in the nurses’ notes, you either have to explain it away in the notes or you have to write a care plan on it" depending upon its severity, says McRae.

Nurses generated ideas on care planning after the inservice. After two nurses were sent to a Health Care Financing Administration seminar on care planning, the agency developed a QI process team to develop a new care planning process. This new process is being piloted for 90 days and may be implemented in all branches after evaluation.

The new process calls for nurses to make a "problem list" of all the patient’s problems upon admission, McRae says. The problems on the list are assessed and updated each visit. Previously, nurses picked the patient’s two main problems upon admission. The problems were assessed and the list updated once every 30 days during the supervisory visit.