Home care is different from institutional care in a
number of ways. One crucial difference is that field staff members are
essentially working without direct supervision on a routine basis. The
cost of providing direct supervision for staff as they provide services
to home care patients is prohibitive. Consequently, providers are
vulnerable to claims that they failed to adequately supervise staff.
These claims may include allegations of negligence and fraud and abuse.
Perhaps the
greatest risk involves staff members who say they made visits that they
really did not make. Changes in patients' conditions may not be
addressed when visits are missed. Visits that are claimed, but turn out
not to have been made after all, are also a common basis for
allegations of fraud and abuse.
In view of
inherent limitations on agencies to directly supervise field staff, what
is the applicable standard of care that must be met? Generally
speaking, appropriate supervision means that agencies must make
reasonable efforts to ensure that field staff meet applicable standards
of care. Reasonable efforts to ensure adequate supervision may include
the following:
- New
employees may be required to make several visits with experienced
employees with proven track records so that any deficiencies in
abilities or practices of new staff can be determined as quickly as
possible. The results of these visits must, of course, be documented.
- Agencies should
develop and implement a policy and procedure that requires random
supervisory visits. Thereafter, managers should make "unannounced"
supervisory visits to patients' residences at all hours of the day and
night so that employees understand that they may be directly supervised
at any time without notice.
- Managers
may also wish to investigate commercially available systems for
tracking the arrival and departure of field staff members at each
patient's home. These systems may require staff to place a telephone
call that registers in a computer when they arrive at patients' homes
and again when they depart.
Of course, these systems
are not foolproof. Instances have been reported in which staff members
paid patients and/or family members to call in for them as though the
worker arrived and departed patients' homes. To the extent that the use
of such systems makes it clear that agencies are using reasonable means
to help verify that services were actually rendered, even if the system
is circumvented, it helps to ensure that agencies have adequately
managed risks associated with visits that are not made as scheduled.
- Agencies
should also develop and implement policies and procedures that require
patients and/or someone else present in patients' homes when visits are
made to sign a document verifying that services were provided. If the
patient cannot sign and no one else is present to sign, staff should be
required to provide a detailed explanation for missing signatures.
- Quality
assurance staff should conduct retrospective audits to make certain
that signatures from patients and/or family members verifying services
are routinely obtained. When there are a number of instances in which
specific staff members failed to obtain signatures as required, despite
the presence of a written explanation, further investigation must be
conducted to determine why signatures are missing on multiple occasions.
- Agencies
should continue to use patient satisfaction surveys to assist them to
satisfy their obligation to monitor workers. Agency staff members
sometimes correctly observe that most of the surveys returned by
patients fall into a category that can best be described as: "We love
our nurse!" Nonetheless, valuable information can occasionally be
gleaned from surveys.
For example, a patient of an agency
responded to a survey by saying that he was quite pleased with the care
provided, but wished that the agency would not send a different nurse
every day. The staff was initially quite puzzled by this response since
their records showed that the same nurse had visited the patient each
day. Following further investigation, however, the staff was astounded
to learn that the agency worker was "subcontracting" the care of the
patient to members of an extended family so that, indeed, the patient
was being cared for by a different "nurse" each visit!
It is
impossible for agencies to duplicate the supervision provided by
institutional providers. Nonetheless, reasonable efforts to supervise
field staff will work in agencies’ favor when workers' performance is
scrutinized.
©2012 Elizabeth E. Hogue, Esq. All rights reserved.
Nice article..
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