Visiting Nurses & Therapists

Accredited Home Care offers superior home health care from licensed, screened and highly experienced nurses and therapists.

Patient services are provided without regard to race, color, religion, age, sex (an individual’s sex, gender identity, sex stereotyping, pregnancy, childbirth and related conditions), sexual orientation, disability (mental or physical), communicable disease, or national origin.

Click to read the Medicare Home Healthcare Booklet

Home Health Services by Discipline

• Skilled Nursing: RNs & LVNs provide patient self-care education, wound care, injections, catheter & ostomy care
• High Tech Nursing: Administration of IV drug therapy, enterostomal nursing (advanced wound care)
• Physical Therapists: Provide pain management, instruction on home exercise & daily living activities, hot/cold & massage therapies
• Occupational Therapists: Assist home care patients in restoring functional independence & self care
• Speech Therapists: Assist patients in restoring communication, evaluate swallowing disorders, evaluate & treat speech and language disorders
• Medical Social Workers: Perform home assessments to identify social, emotional, and financial concerns of family and patient
• Certified Home Health Aides: Assist patients with grooming, personal hygiene, toileting, provide companionship and assist with other daily living activities
• Review Our Home Health Service Area (pdf file)
• Review our Home Health Contracts/Payer List (pdf file)

Our Home Health Services

Home Safety Assessment

Patients will receive information regarding basic home safety

1. Upon admission, the patient’s home will be assessed using the home safety assessment and checklist.
2. Based on the results of that assessment, the patient and family/caregiver learning needs will be identified.
3. Using the assessment, written and verbal information appropriate to the patient’s environment will be used as a basis for patient instruction.
4. The information that will be reviewed with every patient will include:

• Fire safety – Smoking, smoke detectors, fire escape route, burns, electric blankets, heating pads, oxygen therapy precautions, space heaters, cooking safety, flammable liquids, and storage of papers and boxes.
• Electrical safety – Extension cords, electrical cords, overloaded circuits, outlets, light bulbs, grounding, and electrical appliances.
• Environmental and mobility safety – Fall prevention techniques, wheelchair safety, walker safety, exits/passageways, use of handrails, loose carpets, stairway safety, adequate lighting, emergency medical plan, disaster plan.
• Bathroom safety – Nonskid mats, slippery surfaces, grab bars, water temperature.
• During subsequent home visits, clinicians will continually assess the patient and family/caregiver compliance to home safety and re-instruct when safety issues surface.
• Documentation of patient and family/caregiver instruction in the clinical record will include:
• Information taught
• Adaptations made to the environment
• Patient and family/caregiver understanding
• Return demonstrations in use of equipment, if appropriate
• Response to teaching
• Additional learning needs

IV Administration of Medications

1. A physician order (or other authorized independent practitioner) will be obtained for approved IV medications and solutions.
2. All orders for IV medications and solutions will specify medication name and dosage, diluents type and amount, route, frequency of administration, and rate of infusion.
3. The patient receiving IV medications and solutions should have received his/her first dose of prescribed medicine in a hospital setting, in a physician’s office, or under the supervision of a physician or his/her representative prior to admission to Accredited Home Health Services, without evidence of allergic reaction, unless prior approval is obtained by consultation with the Clinical Supervisor.
4. IV medications and solutions will only be administered through a peripheral or central venous line.
5. Laboratory work, as indicated for each medication or solution, will be ordered by the physician (or other authorized independent practitioner).
6. Only drugs that are approved by the Food and Drug Administration (non-investigational) will be administered unless prior approval is obtained by consultation with the Clinical Supervisor.
7. Only medications and solutions that are prepared by a pharmacy and are properly labeled with patient’s name, name of drug, dosage, dilution, date of preparation, expiration date, initials of preparer, and any special instructions will be administered.
8. Patient-specific anaphylaxis kits will be supplied by the home infusion company in the following instances:

• Patient is receiving an approved first-time dose of medication in the home
• Patient has numerous medication allergies
• At physician’s (or other authorized independent practitioner’s) request/order

1. A physician must be notified if any of the following circumstances occur:

• If clinical findings are abnormal
• If laboratory findings are abnormal
• If any allergic or toxic symptoms are exhibited by the patient
• If drug regimen review shows an alternative pharmacotherapeutic plan that could achieve safer, more effective, and more economical patient care
• If anaphylaxis occurs and/or different medication is required to treat
• When proper placement of a central venous catheter is questioned
• If repeated difficulty occurs in establishing a peripheral line

Pain Assessment & Pain Management

1. A pain assessment screening form shall be completed at the initial assessment to determine whether the patient needs a referral, and/or needs to be monitored for ongoing pain. SN will determine if the patient needs re-evaluation, or is at high risk for experiencing pain and requires a more in depth pain assessment.
2. Patients will continue to be monitored at re-assessment by evaluating the following parameters:

• Pain Self-reported – measured by Wong-Baker scale
• Pain Reported by PCG – measured by Wong-Baker scale (8 or higher considered severe pain)
• Effectiveness of analgesia or non-pharmacological methods

1. All therapies used in pain intervention will be coordinated under the primary physician’s recommendations.
2. The skilled nurse will record pain assessment on the flow chart.
3. The skilled nurse will assess the home environment, and assist the family in determining effective methods of pain management with comfort measures.
4. A skilled nurse may educate a willing patient/caregiver in all aspects of pain management including other pain management techniques (such as biofeedback, stress reduction, imaging, yoga, etc.) as MD prescribes:

• The pain process
• The risk for pain
• The pain assessment process
• The importance of effective pain management
• Methods for pain management, when identified as part of treatment
• Potential limitations of pain management modalities
• Side effects of pain treatment

1. The skilled nurse will communicate all pertinent information between staff members, patient, family, PCG and MD.
2. The patient’s pain management needs will be updated based on ongoing assessments by clinical staff, which examine the patient’s individual needs and response to pain intervention.
3. Frequency of pain assessment will be determined by the patient’s individual response to pain and the interventions utilized.

Wound Care

1. Initial Wound Assessment

• Classification – Staging for pressure ulcers as Stage 1, 2, 3 or 4

1. Non-blanchable erythema of intact skin; heralding lesion of skin ulceration.
2. Partial-thickness skin loss involving epidermis or dermis; ulcer is superficial; presents as an abrasion blister or shallow crater.
3. Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; ulcer presents as a deep crater with or without tunneling of adjacent tissue
4. Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, support structures.

• Presence of eschar makes wound unstagable

1. Documentation: “Unable to accurately stage due to presence of eshar.”
2. Once eschar is removed the wound is then staged.
3. Stage 3 & 4 cannot be revised in staging

• Depth

1. Partial: through the first layer of skin (epidermis).
2. Full thickness: extended through epidermis and dermis and may involve subcutaneous tissue, muscle, and bone.

• Color of wound bed
• Location
• Measurement

1. Wounds are measured for length and width from wound edge to wound edge using the face of a clock as a landmark.
2. Length- measured from twelve o’clock (toward top of patients head) to six o’clock (direction of patients feet).
3. Width- measured from three o’clock to nine o’clock.
4. Depth- The distance from the visible surface to the deepest point in the wound. Depth is measured by gently inserting a cotton-tipped applicator into the deepest portion of the wound and grasping the applicator with thumb and forefinger at the point corresponding to the wound margin. After carefully withdrawing the applicator, maintaining the position of the thumb and forefinger, measure the tip of the applicator to the position of the thumb and forefiner.
5. Tunneling/Undermining- measure as length & width and to the deepest portion
6. All measurements will be recorded in centimeters.
7. Measurements will be done at initial assessment and weekly thereafter by the case manager (or designee).

• Wound bed- describe the wound bed color. This may be mixed.
• Surrounding tissue (peri-wound skin) – look for warmth, swelling, redness, pain, exudates or color changes.
• Drainage- document amount, color, consistency

1. Serous: clear, watery plasma
2. Sanguinous; bloody
3. Serosanguinous: plasma and red blood cells
4. Purulent: thick, yellow, green, or brown. This may require medical doctor follow-up if not previously noted.

• Pain- document presence or absence of pain and location. Document when pain occurs.

1. Greater with elevation or when dependent

• Odor- if odor is foul and had not been present previously it may require medical doctor attention.

2. Ongoing Assessment

• Wounds are re-assessed every skilled nursing visit
• Re-assessment includes:

1. Weekly measurements recorded on the clinical notes. Description of wound and surrounding tissue, drainage type, amount, and odor.
2. At visits where wounds are not due to be measured, if visible include description of:
3. Wound bed and surrounding tissue
4. Drainage type and amount
5. Odor

• Changes in wound or surrounding tissue indicating a deterioration of the wound or requiring a change in therapy will be reported to the supervising physician and discussed with the home health supervisor.

3. Wound Treatment

• All wounds will be treated under the supervision of a licensed physician.

1. Wound care will be discussed with the supervising physician and recommendations made during the initial assessment and follow-up assessments as needed.
2. Wound care orders are written specific to the products to be used and frequency of treatment.

• Documentation of the wound care will include products used and patient’s response including any evidence of improvement or deterioration of the wound.
• If a caregiver is available, wound care may be taught. This will include demonstrations and return demonstration, which will be documented in the clinical note.

4. Wound Care Supplies

• Irrigation solutions should be dated once opened and disposed of after 1 week
• All supplies must be kept in a clean environment, contained in either a bag or box.

5. All appropriate Infection Control Policies/Standard Precautions will be applied when giving wound care in the home.

Care Planning

1. Plan Of Care: The clinical plan of care includes:
   1. Pertinent primary and secondary diagnoses
   2. Food or drug allergies
   3. Homebound status
   4. Goals/outcomes to be achieved
   5. Patient’s mental status
   6. Functional limitations
   7. Activities permitted
   8. Safety measures
   9. Nutritional requirements
   10. Medications and treatments
   11. Specific procedures to be performed by therapies, including amount, frequency, and duration
   12. Supplies and equipment required
   13. Discharge or referral plans
   14. Discharge teaching
   15. Frequency and duration of visits
   16. Prognosis
   17. Rehabilitation potential
   18. Other appropriate items such as precautions and contraindications
2. Clinician: Any Nurse, PT, OT, ST, MSW, or CHHA involved in the care of a patient, either directly or indirectly, including administrative, management, and supervisory personnel.
3. At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver.
4. All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including but not limited to:
   • Individualized patient needs and resultant problems related to care, functional status, and family/caregiver support system
   • Changes in patient’s condition
   • Clinical drug monitoring, as appropriate
   • Pain and symptom management, as appropriate
   • Psychosocial needs of patient and family/caregiver, as appropriate
   • Patient treatment choices
5. Based on the assessment and conclusions, the plan of care will include, but will not be limited to:
   • Identified patient problems and needs
   • Reasonable, measurable, and individualized goals
   • Specific services to be provided
   • Actions to be taken to meet the patient goals
   • Type, frequency, and duration of above actions
   • Equipment and supplies
   • Prognosis
6. The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals.
7. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.
8. Patient receiving physical therapy or speech therapy only will have a plan of care initiated by the primary physical therapist or speech therapist within 48 hours of completion of the initial assessment.
9. The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care.
10. The frequency of the review of the plan of care will be based on changes in the patient’s health status, needs, and the environmental factors affecting care. The clinicians will be responsible to revise the plan of care or update the plan at least every 60 days.
11. Changes in the plan of care will be noted with the following documentation:
    • Assessment
    • Clinical notes
    • Verbal orders
12. Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes.
13. Problems and/or needs related to patient’s condition, desires, abilities, family/caregiver support systems, and relevant medication monitoring will be included in the plan of care.
14. Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved.
15. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes.
16. The Clinical Supervisor or designee will review the plan of care for all patients.