Best Practices Tip! Do you have a system in place to obtain annual physician orders for APC services authorized by the State? You should be sure there

The Recipe for APC Best Practices Objectives Review the Basic Regulations regarding Advanced Personal Care, i.e. hiring, training, and supervision. Discuss Effective APC Training Protocols. Identify Best Practice Tools to protect you and your company when it comes to delivering APC services. Authorization of APC All APC units must be authorized by the State Agency, The Plan of Care must be developed, reviewed, and updated by an RN in cooperation with State Agency The Plan of Care must be approved by the participants physician at least annually i.e. you must obtain physician orders for APC services. 1

Best Practices Tip! Do you have a system in place to obtain annual physician orders for APC services authorized by the State? You should be sure there is a process in your organization to obtain annual physician orders. Let s Review the Basics.Who is Eligible to be an APC Aide? In addition to meeting the basic personal care aide requirements, the Aide may only be eligible to be an APC Aide if they are: 1. Currently Licensed LPN or CNA, or are a 2. Competency Evaluated Home Health Aide having completed both written and demonstration portions of the test required by DHSS, (A Home Health Agency would have had to issue this testing) or 3.Successfully (what does that mean?) worked for the provider for a minimum of three (3) months while working at least fifteen hours per week (so what if she only worked 14 hours one week during the 3 month period?) These regulations can put a Provider at risk so be sure to verify the hours worked or you could potentially be out of compliance. Aides that are LPNs/CNAs may waive the 8 hours of classroom training (but be sure you put a waiver form in their personnel files ). Aides that meet the eligibility to be trained as an APC Aide in #2 & 3 above,, must still undergo an additional 8 hours of classroom APC Training 8 Hours of Classroom. APC Classroom Training shall include: Observation of a participant and reporting Application of ointments/lotions to unbroken skin. Manual assistance with oral medications. Prevention of decubiti Enemas Bowel routines (suppositories/sphincter stimulation). Basic Personal Care for persons with ostomies/catheters and cleaning of catheter bags. 2

APC Training Con t Passive Range of Motion Exercises Use of Lifts for Transfers Positioning and Support of the Participant Applying non-sterile to superficial skin breaks, Universal Precautions as defined by CDC. Waiving of APC Classroom Training 8 Hours of Classroom Training may be waived if: 1. The Aide is an LPN or CNA; or 2. The Aide was previously trained as an APC aide by a MoHealthNet Provider; AND 3. Has been employed at least half time by an MoHealthNet InHome provider as an APC aide within the prior six months. The regulations do not address whether competency tested Home Health Aides can waive the 8 hours of APC classroom. (Documentation for #2 and #3 must be obtained and filed in the APC Aides personnel file.) Best Practice Tip! Waiving APC Classroom Training: It may be more prudent to train your APC aides rather than waive the training unless you know for sure they received appropriate training and you can verify the previous APC training and their work experience in writing!!! 3

Training Aides on APC Tasks Videos can serve as a great tool for Aide training, but they should not serve as the primary method for teaching some of the more clinical tasks associated with APC services. Hands On experience in a lab setting can afford your Aides the ability to become comfortable with the tasks prior to performing them on an actual participant. Best Practices Tip! If you have a relatively large APC caseload, consider investing in a Aide Training Dummy. These training devices can provide your aides with the ability to develop hands-on skills prior to walking into a home setting. Competency Testing of APC Tasks CNAs/APC Trained Aides must be competency tested prior to performing any APC task for any participant for the first time. RNs may observe these tasks in the lab or home setting: Application of medicated lotions, ointments or dry, aseptic dressings to unbroken skin including Stage 1 decubitus. Application of aseptic dressing to superficial skin breaks or abrasions as directed by licensed nurse Manual assistance with noninjectable medications as set up by a Licensed nurse. Passive Range of Motion 4

Best Practice Tip! You may want to think twice before allowing your Aide to assist with Medications set up by another Provider s/agency s Nurse. if a legal issue arises, who is liable the Provider Nurse, your Company for allowing the Aide to assist with Meds you did not set up, or Both? Competency Testing of APC Tasks RNs may observe these tasks in the home setting ONLY: Ostomies(including tracheostomies, gastrostomies, colostomies all well-healed stomas) which includes changing bags, and soap and water hygiene around ostomy site. External, indwelling and suprapubic catheters, which includes changing bags, and soap and water hygiene around site. Removal of external catheters, inspect skin and reapply catheter. Administration of prescribed bowel programs, i.e. using suppositories and sphincter stimulation per protocol and enemas (prepackaged only) Use of assistive devices for transfers. Documentation of APC Training in Personnel File Auditors will be looking for: 1. Documentation of the 8 hours of classroom APC training including dates and topics covered (be sure you include all mandated topics). 2. Documentation of any waiver of the 8 classroom hours of APC training. 3. Signed Statement (s) by the RN certifying that the APC Aide has been successfully checked off on each task the aide is required to perform. 5

Best Practice Tips! I recommend you check off those tasks allowed to be checked off in the lab setting as a part of your APC Classroom training to be sure all APC Aides have these skills checked off. Do you have a process in place to ensure your Schedulers know which APC tasks the APC aides have been checked off on? We have given our Aides APC sign off cards to carry in their billfold so that when an RN checks them off on a task, they can sign their card and the Aide can always know for sure which tasks she/he is allowed to perform. Nursing Supervision of APC Services APC Services should include at least the following for Supervisory Visits: 1. RN/LPN - Monthly RN Authorized Nurse Visits to monitor the adequacy of the Plan of Care to meet the needs and conditions of the client and evaluate the client s condition. 2. Every six (6) month RN Nurse Visits to monitor the Plan of Care and supervise the APC Aide. 3. The RN must be available by phone any time a client is receiving APC services. (Don t forget to complete a GHE/LOC form each month!) Best Practices Tips! Develop a Process to ensure your nurse conducting the RN Auth visits remembers she is to also supervise the APC Aide monthly and document that the Aide is following the Plan of Care. Many times nurses are so accustomed to performing weekly meds set ups, they forget to document review of the Plan of Care and supervision of APC Aide. Consider selecting two months out of the year (6 months apart from each other) to make the RN Supervisory visits. For example, we know that in March and September, the RNs will make the RN Auth visits for those APC participants and document appropriate supervision. 6

Advanced Respite Care Advance Respite Services are maintenance service provided to a participant with special needs for the purpose of temporary relief to a caregiver who lives with the participant. Includes, but not limited to: Turning/positioning/transferring from bed to chair with our without assistance of assistive device. Assistance with elimination,i.e. ambulation, urinal, bedpan, catheters, and/or ostomies Behavior disorders or disruptive behavior which requires close monitoring Advance Respite Care Prompting for self-administered medications or manual assistance with oral medications. Special monitoring/assistance due to swallowing problems. Basic respite needs with a higher level of oversight. Advanced Respite Worker Training In addition to meeting the basic training requirements of the Program, the Advanced Respite Worker must receive additional training provided by the RN following the assessment of the client s condition and needs. The RN must fully train the worker to perform the service and personally observe successful execution of the service. The RN should document and sign off on this in the worker s personnel file. 7

Best Practices Tips! If our Advanced Respite participant requires an APC task, then we ensure that the worker is APC trained and competency checked off. Do the regulations require this NO, but it seems like a prudent business decision. Nursing Supervision of Advance Respite Services Advanced Respite Services should include at least the following for Supervisory Visits: 1. Monthly Nurse Visits to monitor the adequacy of the Plan of Care and the client's condition. 2. Every six (6) month RN Nurse Visits it to monitor/supervise the Aide. Unless the client has a need for or is getting RN Auth visits, the State most likely will no longer authorize these Supervisory visits. The Provider is still obligated to do them, but they are non-billable. Let s Review the Basics Definition of APC Services! Maintenance services provided to assist a participant with a stable, chronic condition with ADL when such assistance requires devices and procedures related to altered body function. 8

So what exactly does this mean? Maintenance services means that the participant has a chronic condition that most likely will not change this care need is a part of their life, i.e. ostomies, catheters, transfers, etc. But what about participants that have G-tube feedings or even chronic wounds? Many times these participants p do not qualify for Home Health care because their condition is chronic and helping with G-tube feedings or wound care may not be deemed as skilled care. So what happens to these participants? Is APC services an option for them? In some cases it may be. So exactly what does this mean? While the list of examples of APC tasks seem very specific, over the years Providers have looked at these regulations and found ways to expand them somewhat to help some of the more chronic participants to remain in their homes. Is this legal.let s take a look at the State Board of Nursing view on Delegation! Delegation of Duties! In order to meet the increasing need for accessible, affordable, quality health care, RNs must coordinate and supervise the delivery of nursing care. This may include the delegation of nursing tasks to licensed and unlicensed health care personnel. Te RN maintains the ultimate responsibility and accountability for the management and provision of nursing care. 9

Delegation of Duties The RN is responsible for an individual assessment of the participant and situational circumstances, and for ascertaining the competence of the licensed or unlicensed health care worker before delegating any tasks. Supervision, monitoring, evaluation and follow- up by the RN are crucial components of delegation. The licensed/unlicensed worker is responsible for accepting the delegated task and for his/her own actions in carrying out the task. Delegation Decision-Making Tree Must comply with the Missouri State Nurse Practice Act Is based upon the RNs assessment of the situation, the knowledge/skill required to perform the task, implications for the participant/family, and appropriate RN accountability and supervision. Any Delegation of Duties should be re-evaluated evaluated and adjusted as needed to ensure the safety of the participant. Five Rights of Delegation Right Task Ask yourself if this task is appropriately being delegated for this participant? Right Circumstances Is this task being performed in an appropriate participant setting with available resources. Right Person Do we have the Right person delegating the Right Task to the Right person to be perform on the Right person. 10

Five Rights of Delegation Con t Right Direction/Communication Is there a clear/concise description of the task, including its objective, limitation, and expectations. Right Supervision Is there appropriate monitoring, evaluation, interventions, as needed and feedback? Review the Delegation of Duties Decision-Making Tree Walk the following tasks through the Decision-Making Tree: Medication Administration by Aide Assistance with G-Tube Feedings So can our list of APC tasks be expanded? I have spoken with MMAC regarding this issue: 1. If we have physician orders for the service, and 2. If the RN provides the special training and supervision. 3. And the APC Aide is willing to take responsibility for the task, then the answer may be yes. 11

Questions or Comments? Please share your Best Practices with the group! 12