Internship Report -- Home Health

Internship Report -- Home Health Agency

Background of the Organization

The organization is a privately owned and operated home healthcare agency. It maintains two facilities serving different parts of large metropolitan area. The organization provides home health services to patients discharged from acute care clinics and hospitals with continuing needs for medical care at home beyond the capabilities of patients and their families to maintain. Agency personnel consist of approximately 40 certified nurse assistants (CAN), twelve registered nurses (RN), two physicians (MD), four office managers, and various administrative assistants and support office staff. Eight of the RNs employed by the organization actually deliver patient services; the other four work exclusively as field supervisors.

One-third of the agency's clients require acute nursing care for long-term management of medical conditions and two-thirds of the agency's clients receive less intensive general health support furnished primarily by CNAs. Approximately eighty percent of agency clientele receive services that are eligible for federal reimbursement by Medicare and Medicaid. Ordinarily, the office managers schedule all appointments and distribute work assignments to the available staff on a continuing basis. Certified nurse assistants deliver most home health services unless they require more advanced services. Those services are furnished by the RNs on staff.

The supervisory RNs do not usually deliver services directly but are sometimes assigned to furnish medically necessary acute services in a back-up and emergency capacity. Otherwise, they maintain an up-to-date copy of CAN and RN staff schedules and responsibilities and make field visits to patients' homes to make periodic inspections and assessments of the quality of care being furnished by agency personnel. The supervisory RNs also make arrangements to conduct occasional site visits in between scheduled care delivery appointments to have the opportunity to interview clients about the quality of the care they receive from agency personnel without the care deliverer present. The RN supervisors file daily field reports and weekly status reports detailing their findings from the field.

Research Method and Process

This research project consisted of direct observation and involvement of the researcher in the internship capacity and on face-to-face interviews with agency supervisors and office managers. Throughout the internship, the researcher took regular notes detailing a wide range of agency-related matters of a non-confidential nature. The researcher also conducted informal interviews with two office managers (one of whom was also the facility's HIPAA Information Security Officer (ISO) and three supervisory RNs. The researcher then consulted the notes taken throughout the internship, identified the five specific major problems encountered by the agency that came to light during the internship period and incorporated all recorded information into this report detailing them and proposing solutions. In most cases, the solutions described are those that the agency implemented to resolve the problems described.

Identification and Synopsis of Problems Affecting the Organization

Last year, the agency encountered the following problems:

1. Nosocomial Infections -- Numerous patients contracted chronic infections of the same types as those considered "hospital-acquired infections" when they occur in clinical settings. In most instances, the infections involved the urinary tract and were attributable to urinary catheters. Several patients contracted wound infections at surgical sites and two patients contracted an infection at fixed intravenous sites. The RN supervisors who investigated the problem determined that some of the CNAs delivering services had become lackadaisical about hand washing and about observing basic antiseptic protocols in connection with wound dressing and catheter insertion techniques.

2. Bedsores -- Several patients contracted decubitus ulcers requiring acute care to resolve. The RN supervisors who investigated the problem determined that some of the CNAs delivering services had become careless about standard procedures for preventing bedsores. The supervisor determined that while the CNAs performed the techniques required of them during their visits, they had failed to properly emphasize the importance of turning patients frequently to family members and/or that they had failed to provide adequate instructions in that regard.

3. Tardiness and Missed Appointments without Adequate Notice -- the agency received several complaints from clients or from their family members about service providers who had failed to keep scheduled appointments without any notice. There were also numerous complaints about late arrivals at the homes of patients. The supervisor determined that all of the complaints about missed appointments related to two CNAs; they determined that the tardiness complaints pertained to many service providers but that in the vast majority of cases, the delays were unavoidable and attributable to delays incurred by the service providers at the homes of previously scheduled patients.

4. Unnecessary Referrals for Services and Misstatements of Public Program Eligibility -- in several instances, patients had been referred inappropriately for home health services by their physicians. In most of those cases, the patients and their families had also been misinformed about their eligibility for public assistance for the financial responsibility for home health services.

5. HIPAA violations in the Field -- During several unannounced visits by field supervisors, they discovered inappropriate handling of protected health information (PHI) that should have been secured from potential unintentional disclosure. Because these instances were HIPAA violations, they were immediately referred to the respective ISO from the office dispatching the service provider involved. The ISOs determined that the violations were purely unintentional and the result of negligent handling of paperwork for convenience. Typically, paperwork from previous clients or paperwork being amended by the service providers involved were carelessly left in the open at other patients' homes where they could have been unintentionally exposed to being viewed by non-privileged individuals.

Description of Solutions

Nosocomial Infections -- the agency implemented mandatory supplemental training for all home health service providers. Those training sessions emphasized antiseptic preparation, insertion, and inspection of Foley catheters to prevent nosocomial urinary tract infections. They also covered wound care and, more generally, the importance and mandatory nature of proper hand washing.

Bedsores -- the agency provided additional training in the form of a mandatory one-session review class emphasizing the importance of involving family members in the prevention of bedsores and of the need to make accurate assessments of the ability of family members to fulfill related responsibilities.