Home Health Competency Management System NURSING

Home Health Competency Management System: Nursing is published by Beacon Health, a division of HCPro, Inc. Copyright Cover Image Thank You, 2011. Used under license from Shutterstock. All rights reserved. Printed in the United States of America. 5 4 3 2 1 Download the additional materials of this book at www.hcpro.com/downloads/9710. ISBN: 978-1-60146-883-3 No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro, Inc., provides information resources for the healthcare industry. HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Lynn Riddle Brown, RN, BSN, CRNI, COS-C, Author Justin Veiga, Associate Editor Jamie Carmichael, Associate Editorial Director Lauren McLeod, Editorial Director Adam Carroll, Proofreader Mike Mirabello, Senior Graphic Artist Matt Sharpe, Production Supervisor Shane Katz, Cover Designer & Art Director Jean St. Pierre, Senior Director of Operations Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro, Inc. 75 Sylvan Street, Suite A-101 Danvers, MA 01923 Telephone: 800/650-6787 or 781/639-1872 Fax: 800/639-8511 E-mail: customerservice@hcpro.com Visit Beacon Health online at: www.beaconhealth.org 09/2011

CONTENTS A. Introduction...ix B. Cardiovascular...1 1. CHF Management...1 2. DVT Management...3 3. Hypertension Management...5 4. Post-CABG Management...7 5. PT/INR Monitoring...9 6. Stroke Management...11 7. Subcutaneous Anticoagulation Therapy...13 C. Endocrine...15 1. Blood Glucose Monitoring...15 2. Diabetes Management...17 D. Gastrointestinal...19 1. Biliary Drainage Tube or T-Tube...19 2. Bolus Feedings Through Enteral Feeding Tube...21 3. Continent Ileostomy Intubation...23 4. Emptying GI Ostomy...25 5. Enemas...27 6. Enteral Feedings...29 7. Enteral Pump Feedings Through Enteral Feeding Tube...31 8. Fecal Impaction...33 9. Gastrostomy Tube Replacement...35 10. Gastrostomy Tube Site Care...37 iii

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM 11. GI Ostomy Irrigation...39 12. GI Ostomy, Application of One-Piece...41 13. GI Ostomy, Application of Two-Piece...43 14. Irrigation of Continent Ileostomy...45 15. Medication Administration Via Enteral Feeding Tube...47 16. Ostomies...49 17. Rectal Tube...51 E. Genitourinary...53 1. Catheterization of Continent Urinary Diversion...53 2. Condom Catheter...55 3. Coude Indwelling Urinary Catheter...57 4. Emptying GU Ostomy...59 5. GU Ostomy, Application of One-Piece...61 6. GU Ostomy, Application of Two-Piece...63 7. Indwelling Urinary Catheter...65 8. Intermittent Catheterization...67 9. Irrigation of Continent Urinary Diversion...69 10. Irrigation of Indwelling Urinary Catheter...71 11. Nephrostomy Tubes...73 12. Sitz Bath...75 13. Suprapubic Indwelling Urinary Catheter...77 14. Urinary Catheter Care...79 15. Urostomies...81 F. Infusion Therapies...83 1. Anti-Infective Therapy...83 2. Biotherapy Administration...85 3. Cytotoxic Drug Administration...87 4. Cytotoxic Drug Precautions...89 5. Enzyme Replacement Therapy...91 iv

NURSING 6. First Dose Administration in Home Setting...93 7. Flow Control Devices...95 8. Immunoglobulin Therapy Administration...97 9. Inotropic Drug Administration...99 10. IV Push Medications...101 11. Miscellaneous Drug Administration in Home Setting...104 12. ON-Q Pump...106 13. Pain Infusion Therapy...108 14. Parenteral Nutrition Therapy... 110 15. Patient Education for Infusion Therapy... 112 16. Subcutaneous Infusion Therapy... 114 G. Integumentary...116 1. Alginate Dressings... 116 2. Bioactive Wound Dressings... 118 3. Cadexomer Iodine Dressings... 120 4. Collagen Matrix Dressings...122 5. Composite Dressings... 124 6. Compression Pump Therapy... 126 7. Compression Wrap Dressings... 128 8. Enzymatic Debriders...130 9. Foam Dressings... 132 10. Gauze Dressings...134 11. Growth Factor Wound Products... 137 12. Honey-Impregnated Dressings... 139 13. Hydrocolloid Dressings... 141 14. Hydrogel Dressings... 143 15. Lower Extremity Arterial Disease Wounds... 145 16. Lower Extremity Neuropathic Disease Wounds...148 17. Lower Extremity Venous Disease Wounds... 151 18. Negative Pressure Wound Therapy...154 v

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM 19. Pressure Ulcer Assessment... 158 20. Pressure Ulcer Treatment...160 21. Providone Iodine Dressings...163 22. Silicone Dressings...165 23. Silver-Impregnated Dressings... 167 24. Skin Tear Treatment... 169 25. Staging Pressure Ulcers... 171 26. Staple/Suture Removal... 173 27. Surgical Wound Treatment... 175 28. Transparent Film Dressings... 177 29. Unna Boot Dressings... 179 30. Wound Drain Care... 181 31. Wound Fillers/Exudate Absorbers...183 32. Wound Irrigation...185 33. Zinc Paste Bandage... 187 H. Laboratory Specimen Collection...189 1. Blood Culture VAD...189 2. Blood Culture Venipuncture... 191 3. Blood Specimen Collection From VAD... 193 4. Culturing for VAD... 195 5. Sputum Specimen Collection... 197 6. Stool Specimen Collection...199 7. Urine Specimen Collection...201 8. Venipuncture...203 9. Wound Culturing...205 I. Musculoskeletal...207 1. Body Mechanics...207 2. Range of Motion Exercises...208 vi

NURSING J. Neurological...210 1. Alzheimer s Disease/Dementia Management... 210 2. Halo Pin Care... 212 3. Seizure Precautions... 214 4. Stroke Management... 216 5. TENS Unit (Transcutaneous Electrical Nerve Stimulation)... 218 K. Other...220 1. Injections...220 2. Palliative Care...222 L. Respiratory...224 1. COPD Management...224 2. Home Oxygen...226 3. Oronasopharyngeal Suctioning...228 4. Pleural Tube Care...230 5. Pneumonia Management...232 6. Pulse Oximetry...234 7. Tracheostomy Care...236 M. Vascular Access Devices...239 1. Aseptic Technique...239 2. Blood Specimen Collection From VAD... 241 3. Catheter Stabilization Device... 243 4. Culturing for VAD...245 5. CVAD Dressing Change... 247 6. Filter Needles...249 7. Hair Removal...250 8. Implanted Infusion Pump...251 9. Implanted Port Access for Therapy...253 10. Implanted Port De-Access and Re-Access Procedure...255 vii

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM 11. Implanted Port De-Access Procedure...257 12. Injection Cap Change...259 13. Management of Infusion-Related Complications... 261 14. Midline Catheter Insertion...263 15. Monthly Implanted Port Flush...265 16. Needlestick Safety...267 17. Occluded Catheter...269 18. Patient Education for VAD...271 19. Peripheral IV Insertion...273 20. Peripheral IV Removal...275 21. PICC/Midline/Non-Tunneled Catheter Removal...277 22. S-A-S-H Procedure...279 23. VAD Flushing Procedure...281 24. VAD Types and Guidelines for Care...283 N. References...287 viii

INTRODUC TION Introduction No matter what changes in homecare, there will always be the need to validate clinician competencies. It is not sufficient to send clinicians into the field assuming they are proficient, simply based on their licensure. Procedures and treatments are forever changing due to evidence-based practices. It is up to agencies to verify that clinicians remain current and proficient in their skills. Due to home health regulations from both federal and state governing bodies, it is imperative for agencies to be able to produce documentation that demonstrates competencies of clinicians in their job duties. This also helps to protect both the agency and clinicians in today s age of increasing litigation. For clinicians, signing a document verifying their competency gives them ownership of the responsibilities associated with the competency. It gives the agency tools to identify clinician deficiencies early during the orientation process, saving time and resources. Home health is evolving into a more complicated level of care. Without the availability of immediate support, as found in the hospital setting, clinicians must function at a higher level of independence and skill. It is up to the management staff and specialists within the agency to ensure that clinicians can perform at this higher level. Standard, written competencies serve as an effective way to document and validate this level of performance. The competencies listed within the nursing sections of this book can be used for both registered nurses and licensed practical nurses based on the allowances of the state in which they practice and the specific policies within the homecare agency. The competencies have been set up in a generic fashion, with each constructed in a way that can accommodate variances in policies or protocol between agencies. This also allows for changes within policies or protocols without having to revise the competencies. The competencies have been organized by the body system they affect or the function they are related to. It is a comprehensive list of competencies, covering everything from the orientation process to the basic visit to the skills performed by nursing staff. The competencies can also be used as a guide for the development of agency policies and for the employee orientation process. ix

DOWNLOAD YOUR MATERIALS NOW Visit the website below for access to your electronic version of Home Health Competency Management System: Nursing. www.hcpro.com/downloads/9710 Thank you for purchasing this product!

NURSING CHF MANAGEMENT Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Demonstrates knowledge of pathophysiology of CHF 2. Demonstrates knowledge of CHF-related complications 3. Verbalizes/demonstrates knowledge of assessment parameters: a. Patient/caregiver knowledge level of disease b. Patient/caregiver level of motivation c. Patient/caregiver learning style d. Social, economic, cultural barriers e. Cognitive, physical, literacy barriers f. Patient/caregiver knowledge of CHF-related complications g. Patient-specific exacerbating factors for CHF h. Physical assessment i. Relevant laboratory values j. Medications 4. Sets and prioritizes goals based on an assessment with patient/caregiver 5. Plan of care individualized based on assessment of patient needs 6. Assesses for need of referrals to other disciplines and obtains orders as needed 7. Implements plan of care: a. Follows agency policies/protocols b. Provides educational materials appropriate for learning style and literacy level 8. Addresses the following educational parameters: a. Patient s symptoms of heart failure b. When to call physician vs. 911 c. Nutritional education d. Physical activity plan e. Weight control f. Laboratory values g. Blood glucose control h. Hypertension management i. Medications j. Reduction of risk factors k. Dyspnea relief measures l. Home oxygen safety m. Lifestyle modification CARDIOVASCULAR 1

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM CARDIOVASCULAR n. Pneumococcal and influenza vaccinations o. Telemonitoring if available p. Daily monitoring parameters 9. Identifies and addresses needs on ongoing basis: a. Monitors compliance b. Evaluates progress toward goals c. Revises goals as needed Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency Comments/action plan: Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 2

NURSING DVT MANAGEMENT Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Demonstrates knowledge of pathophysiology of DVT formation 2. Demonstrates knowledge of DVT-related complications 3. Verbalizes/demonstrates knowledge of assessment parameters: a. Patient/caregiver knowledge level of DVT formation b. Patient/caregiver level of motivation c. Patient/caregiver learning style d. Social, economic, cultural barriers e. Cognitive, physical, literacy barriers f. Patient/caregiver knowledge of DVT-related complications g. Physical assessment h. Relevant laboratory values i. Medications 4. Sets and prioritizes goals based on an assessment with patient/caregiver 5. Plan of care individualized based on assessment of patient needs 6. Assesses for need of referrals to other disciplines and obtains orders as needed 7. Implements plan of care: a. Follows agency policies/protocols b. Provides educational materials appropriate for learning style and literacy level 8. Addresses the following educational parameters: a. Risk factors for DVT b. Symptoms of DVT c. When to call physician vs. 911 d. Nutritional education e. Physical activity plan f. Weight control g. Laboratory values h. Hypertension management i. Medications j. Reduction of risk factors k. Lifestyle modification l. Signs and symptoms of bleeding m. Bleeding precautions associated with anticoagulation therapy CARDIOVASCULAR 3

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM CARDIOVASCULAR 9. Identifies and addresses needs on ongoing basis: a. Monitors compliance b. Evaluates progress toward goals c. Revises goals as needed Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency Comments/action plan: Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 4

NURSING HYPERTENSION MANAGEMENT Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Demonstrates knowledge of pathophysiology of hypertension 2. Demonstrates knowledge of blood pressure classification: a. Normal b. Prehypertension c. Hypertension, Stage 1 and Stage 2 3. Demonstrates knowledge of importance of systolic blood pressure 4. Demonstrates knowledge of hypertension-related complications 5. Verbalizes/demonstrates knowledge of assessment parameters: a. Patient/caregiver knowledge level of hypertension b. Patient/caregiver level of motivation c. Patient/caregiver learning style d. Social, economic, cultural barriers e. Cognitive, physical, literacy barriers f. Patient/caregiver knowledge of hypertension-related complications g. Physical assessment h. Relevant laboratory values i. Medications 6. Sets and prioritizes goals based on an assessment with patient/caregiver 7. Plan of care individualized based on assessment of patient needs 8. Assesses for need of referrals to other disciplines and obtains orders as needed 9. Implements plan of care: a. Follows agency policies/protocols b. Provides educational materials appropriate for learning style and literacy level 10. Addresses the following educational parameters: a. Nutritional education b. Physical activity plan c. Self-monitoring of blood pressure d. Laboratory values e. Medications f. Reduction of risk factors g. Lifestyle modification CARDIOVASCULAR 5

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM CARDIOVASCULAR 11. Identifies and addresses needs on ongoing basis: a. Monitors compliance b. Evaluates progress toward goals c. Revises goals as needed Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency Comments/action plan: Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 6

NURSING POST-CABG MANAGEMENT Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Demonstrates knowledge of pathophysiology of coronary artery disease 2. Demonstrates knowledge of coronary artery bypass graft surgery 3. Demonstrates knowledge of potential postsurgical complications 4. Verbalizes/demonstrates knowledge of assessment parameters: a. Neurological status b. Cardiac status c. Respiratory status d. Pain assessment e. Wound assessment f. Patient/caregiver knowledge level of coronary artery disease g. Patient/caregiver level of motivation h. Patient/caregiver learning style i. Social, economic, cultural barriers j. Cognitive, physical, literacy barriers k. Patient/caregiver knowledge of postsurgical complications l. Physical assessment m. Relevant laboratory values n. Medications 5. Sets and prioritizes goals based on an assessment with patient/caregiver 6. Plan of care individualized based on assessment of patient needs 7. Assesses for need of referrals to other disciplines and obtains orders as needed 8. Implements plan of care: a. Follows agency policies/protocols b. Provides educational materials appropriate for learning style and literacy level 9. Addresses the following educational parameters: a. Cardiac rehabilitation b. Blood glucose control c. Hypertension control d. Cholesterol control e. Nutritional education f. Physical activity plan g. Laboratory values h. Medications CARDIOVASCULAR 7

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM CARDIOVASCULAR i. Reduction of risk factors j. Lifestyle modification 10. Identifies and addresses needs on ongoing basis: a. Monitors compliance b. Evaluates progress toward goals c. Revises goals as needed Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency Comments/action plan: Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 8

NURSING PT/INR MONITORING Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verbalizes/demonstrates knowledge of acceptable parameters for PT/INR based on reason for anticoagulant therapy 2. Performs/verbalizes operation of PT/INR monitor per manufacturer s recommendation: (Monitor: ) a. Mechanical operation of monitor CARDIOVASCULAR b. Troubleshooting c. Verbalizes/demonstrates care of monitor d. Verbalizes/demonstrates use of lancet device e. Verbalizes/demonstrates storage of monitor and test strips f. Verbalizes/demonstrates knowledge of onboard quality control checks 3. Verifies orders 4. Uses two patient identifiers 5. Explains procedure to patient/caregiver 6. Performs hand hygiene according to agency policy/protocol 7. Dons personal protective equipment as appropriate for procedure 8. Maintains bag technique per agency policy/protocol throughout procedure 9. Utilizes standard precautions and aseptic technique throughout procedure 10. Sets up supplies 11. Prepares monitor for blood as per manufacturer s recommendations 12. Disinfects finger 13. Uses lancet device per manufacturer s recommendation for blood 14. Applies blood to test strip per manufacturer s recommendations 15. Applies gauze to finger until bleeding stops, applies Band-Aid as needed 16. Obtains reading off monitor 17. Cleans equipment/environment post-procedure 18. Provides education to patient/caregiver per assessed needs 19. Maintains safe environment for the patient throughout procedure 20. Utilizes OSHA standards for disposal of hazardous materials, waste, and sharps 21. Performs hand hygiene according to agency policy/protocol 22. Documents procedure per agency policy/protocol 23. Takes appropriate actions for abnormal findings or observations Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 9

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM CARDIOVASCULAR Comments/action plan: Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 10

NURSING STROKE MANAGEMENT Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Demonstrates knowledge of pathophysiology of strokes: a. Ischemic stroke b. Hemorrhagic stroke c. Transient ischemic attack d. Recurrent stroke 2. Demonstrates knowledge of stroke-related complications 3. Verbalizes/demonstrates knowledge of assessment parameters: a. Patient/caregiver knowledge level of strokes b. Patient/caregiver level of motivation c. Patient/caregiver learning style d. Social, economic, cultural barriers e. Cognitive, physical, literacy barriers f. Patient/caregiver knowledge of stroke-related complications g. Physical assessment h. Relevant laboratory values i. Medications 4. Sets and prioritizes goals based on an assessment with patient/caregiver 5. Plan of care individualized based on assessment of patient needs 6. Assesses for need of referrals to other disciplines and obtains orders as needed 7. Implements plan of care: a. Follows agency policies/protocols b. Provides educational materials appropriate for learning style and literacy level 8. Addresses the following educational parameters: a. Recognizing signs of a stroke b. Nutritional education c. Physical activity plan d. Self-monitoring of blood pressure e. Laboratory values f. Medications g. Reduction of risk factors h. Lifestyle modification i. Management and rehabilitation of stroke-related deficits: i. Paralysis ii. Cognitive CARDIOVASCULAR 11

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM CARDIOVASCULAR iii. Language iv. Emotional v. Pain j. Management of extremity swelling 9. Identifies and addresses needs on ongoing basis: a. Monitors compliance b. Evaluates progress toward goals c. Revises goals as needed Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency Comments/action plan: Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 12

NURSING SUBCUTANEOUS ANTICOAGULATION THERAPY Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Demonstrates knowledge of disease process being treated with subcutaneous anticoagulation therapy 2. Demonstrates knowledge of classifications of subcutaneous anticoagulation therapy: a. Subcutaneous heparin b. Subcutaneous low-molecular-weight heparin c. Subcutaneous activated factor X inhibitor 3. Demonstrates knowledge of relevant laboratory values to monitor per classification of subcutaneous anticoagula - tion therapy 4. Demonstrates knowledge of adverse effects from subcutaneous anticoagulation therapy and appropriate actions to take 5. Assesses patient for: a. Respiratory difficulties b. Pain c. Peripheral pulses d. Presence of edema e. Dermatological symptoms f. Mental status changes g. Compliance h. Changes in therapy or other medications i. Dietary changes j. Patient/caregiver learning style k. Social, economic, cultural barriers l. Cognitive, physical, literacy barriers 6. Patient/caregiver education includes: a. Diagnosis b. Medication education c. Administration of medication and site rotation d. Storage and disposal of supplies e. Potential adverse effects and when to notify physician vs. 911 f. Fall prevention g. Signs of treatment failure h. Medications/over-the-counter medications/herbal supplements that are contraindicated i. Needed follow-up at discharge 7. Verifies most recent laboratory values prior to initiation of therapy in home 8. Administers subcutaneous anticoagulation therapy using correct technique: a. Appropriate site b. Subcutaneously c. Does not aspirate CARDIOVASCULAR 13

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM CARDIOVASCULAR d. Does not rub injection site e. Does not expel air in prefilled syringes 9. Sets and prioritizes goals based on an assessment with patient/caregiver 10. Plan of care individualized based on assessment of patient needs 11. Assesses for need of referrals to other disciplines and obtains orders as needed 12. Implements plan of care: a. Follows agency policies/protocols b. Provides educational materials appropriate for learning style and literacy level 13. Identifies and addresses needs on ongoing basis: a. Monitors compliance b. Evaluates progress toward goals c. Revises goals as needed Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency Comments/action plan: Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 14

NURSING BLOOD GLUCOSE MONITORING Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verbalizes/demonstrates knowledge of appropriate timing for checking blood glucose 2. Verbalizes/demonstrates knowledge of acceptable parameters for blood glucose 3. Performs/verbalizes operation of blood glucose monitor per manufacturer s recommendation: (Monitor: ) a. Mechanical operation of monitor b. Troubleshooting c. Verbalizes/demonstrates care of monitor ENDOCRINE d. Verbalizes/demonstrates use of lancet device e. Verbalizes/demonstrates storage of monitor, test strips/disk, control solution f. Verbalizes/demonstrates control testing 4. Verifies orders 5. Uses two patient identifiers 6. Explains procedure to patient/caregiver 7. Performs hand hygiene according to agency policy/protocol 8. Dons personal protective equipment as appropriate for procedure 9. Maintains bag technique per agency policy/protocol throughout procedure 10. Utilizes standard precautions and aseptic technique throughout procedure 11. Sets up supplies 12. Prepares monitor for blood as per manufacturer s recommendations 13. Disinfects finger 14. Uses lancet device per manufacturer s recommendation for blood 15. Applies blood to test strip per manufacturer s recommendations 16. Applies gauze to finger until bleeding stops, applies Band-Aid as needed 17. Obtains reading off monitor 18. Cleans equipment/environment post-procedure 19. Provides education to patient/caregiver per assessed needs 20. Maintains safe environment for the patient throughout procedure 21. Utilizes OSHA standards for disposal of hazardous materials, waste, and sharps 22. Performs hand hygiene according to agency policy/protocol 23. Documents procedure per agency policy/protocol 24. Takes appropriate actions for abnormal findings or observations Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 15

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM Comments/action plan: ENDOCRINE Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 16

NURSING DIABETES MANAGEMENT Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Demonstrates knowledge of pathophysiology of diabetes 2. Demonstrates knowledge of diabetes-related complications 3. Verbalizes/demonstrates knowledge of assessment parameters: a. Patient/caregiver knowledge level of disease b. Patient/caregiver level of motivation c. Patient/caregiver learning style d. Social, economic, cultural barriers e. Cognitive, physical, literacy barriers f. Patient/caregiver knowledge of diabetes-related complications g. Physical assessment h. Relevant laboratory values i. Medications 4. Sets and prioritizes goals based on an assessment with patient/caregiver 5. Plan of care individualized based on assessment of patient needs 6. Assesses for need of referrals to other disciplines and obtains orders as needed 7. Implements plan of care: a. Follows agency policies/protocols b. Provides educational materials appropriate for learning style and literacy level 8. Addresses the following educational parameters: a. Nutritional education b. Physical activity plan c. Blood glucose monitors d. Laboratory values e. Sick day management f. Medications g. Reduction of risk factors h. Insulin infusion pump i. Foot care j. Lifestyle modification 9. Identifies and addresses needs on ongoing basis: a. Monitors compliance b. Evaluates progress toward goals c. Revises goals as needed ENDOCRINE Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 17

NURSING BILIARY DRAINAGE TUBE OR T-TUBE Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verifies orders 2. Uses two patient identifiers 3. Explains procedure to patient/caregiver 4. Performs hand hygiene according to agency policy/protocol 5. Maintains bag technique per agency policy/protocol throughout procedure 6. Utilizes standard precautions and aseptic technique throughout procedure 7. Sets up supplies 8. Dons personal protective equipment as appropriate for procedure 9. Site care: a. Removes old dressing b. Performs hand hygiene c. Dons new gloves d. Observes insertion site e. Cleanses site per physician orders f. Places new dressing and secures appropriately 10. Irrigation: a. Prepares syringe with normal saline b. Disinfects injection port and turns stopcock to correct position c. Connects syringe with normal saline and slowly instills amount per physician orders d. Removes syringe and turns stopcock to correct position e. Observes for drainage 11. Drainage bag care: a. Using aseptic technique, opens drainage spout and drains contents into container b. Reseals the drainage spout c. Hangs bag lower than insert site d. Measures and observes contents 12. Cleans equipment/environment post-procedure 13. Provides education to patient/caregiver per assessed needs 14. Maintains safe environment for the patient throughout procedure 15. Utilizes OSHA standards for disposal of hazardous materials and waste 16. Performs hand hygiene according to agency policy/protocol 17. Documents procedure per agency policy/protocol 18. Takes appropriate actions for abnormal findings or observations GASTROINTESTINAL Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 19

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM Comments/action plan: Supervising clinician signature: GASTROINTESTINAL Method of validation: Direct observation Simulation Verbalization Documentation Type of validation: Annual competency Procedure check-off Orientation Employee signature: Self-assessment: Proficient Limited experience No experience 20

NURSING BOLUS FEEDINGS THROUGH ENTERAL FEEDING TUBE Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verifies orders 2. Uses two patient identifiers 3. Explains procedure to patient/caregiver 4. Performs hand hygiene according to agency policy/protocol 5. Maintains bag technique per agency policy/protocol throughout procedure 6. Utilizes standard precautions and aseptic technique throughout procedure 7. Sets up supplies 8. Elevates head of bed 9. Verifies placement of tube as appropriate for enteral feeding tube 10. Checks for residual as appropriate for enteral feeding tube and verbalizes/demonstrates appropriate actions based on agency/policy/protocol and physician orders 11. Flushes enteral feeding tube with 60 ml of water or per physician orders 12. Administers enteral feeding as per physician orders: a. Attaches syringe with removed barrel to feeding tube b. Pinches off feeding tube or clamps as appropriate for enteral access device to prevent air entering and causing distention c. Pours enteral feeding into syringe d. Adjusts rate of flow by height of syringe based on patient tolerance and/or physician orders e. Refills syringe before emptying 13. At completion of bolus feeding, flushes enteral feeding tube with 60 ml of water or per physician orders 14. Secures plug in end of enteral feeding tube 15. Verbalizes/demonstrates appropriate actions to take if feeding does not flow freely from syringe 16. Verbalizes/demonstrates appropriate actions to take if patient experiences symptoms during bolus feeding 17. Verbalizes/demonstrates time frame patient should remain elevated post-feeding 18. Cleans equipment/environment post-procedure 19. Provides education to patient/caregiver per assessed needs 20. Maintains safe environment for the patient throughout procedure 21. Utilizes OSHA standards for disposal of hazardous materials and waste 22. Performs hand hygiene according to agency policy/protocol 23. Documents procedure per agency policy/protocol 24. Takes appropriate actions for abnormal findings or observations GASTROINTESTINAL Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 21

NURSING CONTINENT ILEOSTOMY INTUBATION Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verifies orders 2. Uses two patient identifiers 3. Explains procedure to patient/caregiver 4. Performs hand hygiene according to agency policy/protocol 5. Maintains bag technique per agency policy/protocol throughout procedure 6. Utilizes standard precautions and aseptic technique throughout procedure 7. Sets up supplies 8. Positions patient 9. Places pad under patient as available 10. Dons personal protective equipment as appropriate for procedure 11. Inserts lubricated end of catheter into stoma 12. Irrigates as ordered if catheter plugs with mucus 13. Drains reservoir until stool flow stops 14. Washes catheter with liquid soap and warm water 15. Rinses well 16. Allows to dry 17. Instructs patient/caregiver to wrap in plain white paper towel and store in clean container once dry 18. Cleans equipment/environment post-procedure 19. Provides education to patient/caregiver per assessed needs 20. Maintains safe environment for the patient throughout procedure 21. Utilizes OSHA standards for disposal of hazardous materials and waste 22. Performs hand hygiene according to agency policy/protocol 23. Documents procedure per agency policy/protocol 24. Takes appropriate actions for abnormal findings or observations GASTROINTESTINAL Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 23

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM Comments/action plan: Supervising clinician signature: GASTROINTESTINAL Method of validation: Direct observation Simulation Verbalization Documentation Employee signature: Type of validation: Annual competency Procedure check-off Orientation Self-assessment: Proficient Limited experience No experience 24

NURSING EMPTYING GI OSTOMY Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verifies orders 2. Uses two patient identifiers 3. Explains procedure to patient/caregiver 4. Performs hand hygiene according to agency policy/protocol 5. Maintains bag technique per agency policy/protocol throughout procedure 6. Utilizes standard precautions and aseptic technique throughout procedure 7. Sets up supplies 8. Positions patient 9. Places pad under patient as available 10. Dons personal protective equipment as appropriate for procedure 11. Raises pouch drainage opening to prevent spilling 12. Removes clamp 13. Cuffs bottom of pouch drainage opening 14. Empties pouch 15. Rinses with cool water until clean as needed 16. Cleans and dries pouch draining opening 17. Instills accessory ostomy product as appropriate for patient 18. Closes pouch drainage clamp 19. Cleans equipment/environment post-procedure 20. Provides education to patient/caregiver per assessed needs 21. Maintains safe environment for the patient throughout procedure 22. Utilizes OSHA standards for disposal of hazardous materials and waste 23. Performs hand hygiene according to agency policy/protocol 24. Documents procedure per agency policy/protocol 25. Takes appropriate actions for abnormal findings or observations GASTROINTESTINAL Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 25

NURSING ENEMAS Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verifies orders 2. Uses two patient identifiers 3. Explains procedure to patient/caregiver 4. Performs hand hygiene according to agency policy/protocol 5. Maintains bag technique per agency policy/protocol throughout procedure 6. Utilizes standard precautions and aseptic technique throughout procedure 7. Sets up supplies 8. Positions patient 9. Places pad under patient as available 10. Dons personal protective equipment as appropriate for procedure 11. Tap water/soap suds enema: a. Prepares enema solution and bag per manufacturer s recommendations b. Hangs bag 12 18 inches high c. Assists patient to toilet/bedside commode or places on left side-lying position d. Instructs patient to take deep breath e. Inserts lubricated tip 2 4 inches into rectum f. Slowly infuses solution g. Clamps and withdraws tubing h. Ensures patient is safely sitting on toilet/bedside commode or places patient over bedpan 12. Fleets/mineral oil enema: a. Places patient in left side-lying position and pads under buttocks b. Instructs patient to take deep breath c. Inserts lubricated tip 2 inches into rectum d. Gently squeezes and rolls the bottle e. Maintains pressure until all contents expelled f. Withdraws tip g. Assists patient to toilet/bedside commode or places patient over bedpan 13. Verbalizes actions to take for cramping, expelling solution early, or when flow slows or stops 14. Instructs patient to try to hold for 15 30 minutes based on enema 15. Allows patient sufficient time to pass stool/enema contents 16. Provides perineal care 17. Assist patient with personal care as needed 18. Cleans equipment/environment post-procedure GASTROINTESTINAL 27

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM 19. Provides education to patient/caregiver per assessed needs 20. Maintains safe environment for the patient throughout procedure 21. Utilizes OSHA standards for disposal of hazardous materials and waste 22. Performs hand hygiene according to agency policy/protocol 23. Documents procedure per agency policy/protocol 24. Takes appropriate actions for abnormal findings or observations Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency Comments/action plan: GASTROINTESTINAL Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 28

NURSING ENTERAL FEEDINGS Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verbalizes/demonstrates knowledge of indications for enteral feedings 2. Verbalizes/demonstrates knowledge of enteral access types: a. Nasal feeding tubes b. Gastrostomy feeding tubes c. Jejunostomy feeding tubes 3. Verbalizes/demonstrates knowledge of advantages and disadvantages in each enteral access type 4. Verbalizes/demonstrates knowledge of signs and symptoms of complications associated with each enteral access type 5. Verbalizes/demonstrates knowledge of appropriate actions for complications associated with each enteral access type 6. Verbalizes/demonstrates knowledge of methods of enteral feedings: a. Bolus feedings b. Enteral pump feedings 7. Verbalizes/demonstrates knowledge of advantages and disadvantages in each method of enteral feeding 8. Verbalizes/demonstrates knowledge of potential complications associated with enteral feedings 9. Verbalizes/demonstrates knowledge of appropriate actions for complications associated with enteral feedings 10. Verbalizes/demonstrates knowledge of enteral formulas and indications of use GASTROINTESTINAL Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 29

NURSING ENTERAL PUMP FEEDINGS THROUGH ENTERAL FEEDING TUBE Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verbalizes definition of enteral feeding pump 2. Verbalizes indication for use of enteral feeding pump 3. Performs/verbalizes operation of enteral feeding pump per manufacturer s recommendation: (Pump: ) a. Mechanical operation of device b. Troubleshooting c. Verbalizes/demonstrates care of pump d. Verbalizes change frequency of tubing/cassette 4. Verifies orders 5. Uses two patient identifiers 6. Explains procedure to patient/caregiver 7. Performs hand hygiene according to agency policy/protocol 8. Maintains bag technique per agency policy/protocol throughout procedure 9. Utilizes standard precautions and aseptic technique throughout procedure GASTROINTESTINAL 10. Sets up supplies 11. Elevates head of bed 12. Verifies placement of tube as appropriate for enteral feeding tube 13. Checks for residual as appropriate for enteral feeding tube and verbalizes/demonstrates appropriate actions based on agency/policy/protocol and physician orders 14. Prepares enteral feeding in bag and flush bag if present per physician orders and manufacturer s recommendations 15. Attaches tubing/cassette to feeding bag and pump per manufacturer s recommendations 16. Purges air from tubing/cassette per manufacturer s recommendations 17. Flushes enteral feeding tube with 60 ml of water or per physician orders 18. Administers enteral feeding as per physician orders: a. Attaches to feeding tube b. Enteral feeding pump regulated per physician orders and manufacturer s recommendations c. Labels tubing per agency/policy/protocol 19. At completion of enteral pump feeding, flushes enteral feeding tube with 60 ml of water or per physician orders 20. Secures plug in end of enteral feeding tube 21. Verbalizes/demonstrates appropriate actions to take if feeding does not flow through pump 22. Verbalizes/demonstrates appropriate actions to take if patient experiences symptoms during enteral pump feeding 23. Verbalizes/demonstrates flush frequency for continuous enteral feedings as per agency policy/protocol and physician orders 24. Verbalizes/demonstrates time frame patient should remain elevated post-feeding 25. Cleans equipment/environment post-procedure 31

HOME HEALTH COMPETENCY MANAGEMENT SYSTEM 26. Provides education to patient/caregiver per assessed needs 27. Maintains safe environment for the patient throughout procedure 28. Utilizes OSHA standards for disposal of hazardous materials and waste 29. Performs hand hygiene according to agency policy/protocol 30. Documents procedure per agency policy/protocol 31. Takes appropriate actions for abnormal findings or observations Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency Comments/action plan: GASTROINTESTINAL Supervising clinician signature: Method of validation: Direct observation Simulation Verbalization Type of validation: Annual competency Procedure check-off Orientation Documentation Employee signature: Self-assessment: Proficient Limited experience No experience 32

NURSING FECAL IMPACTION Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verifies orders 2. Uses two patient identifiers 3. Explains procedure to patient/caregiver 4. Performs hand hygiene according to agency policy/protocol 5. Maintains bag technique per agency policy/protocol throughout procedure 6. Utilizes standard precautions and aseptic technique throughout procedure 7. Sets up supplies 8. Positions patient 9. Places pad under patient as available 10. Dons personal protective equipment as appropriate for procedure 11. Checking for fecal impaction: a. Places patient in side-lying position and pads under buttocks b. Instructs patient to take deep breath c. Inserts lubricated gloved finger d. Checks for fecal mass e. Withdraws finger f. Provides perineal care 12. Removing fecal impaction: a. Places patient in side-lying position and pads under buttocks b. Instructs patient to take deep breath c. Inserts lubricated gloved finger d. Hooks index finger around a small piece of feces e. Removes finger and feces f. Cleanses finger with tissue/wipes and relubricates finger as needed g. Withdraws finger h. Provides perineal care 13. Assists patient with personal care as needed 14. Cleans equipment/environment post-procedure 15. Provides education to patient/caregiver per assessed needs 16. Maintains safe environment for the patient throughout procedure 17. Utilizes OSHA standards for disposal of hazardous materials and waste 18. Performs hand hygiene according to agency policy/protocol 19. Documents procedure per agency policy/protocol 20. Takes appropriate actions for abnormal findings or observations GASTROINTESTINAL Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 33

NURSING GASTROSTOMY TUBE REPLACEMENT Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verifies orders 2. Uses two patient identifiers 3. Explains procedure to patient/caregiver 4. Performs hand hygiene according to agency policy/protocol 5. Maintains bag technique per agency policy/protocol throughout procedure 6. Utilizes standard precautions and aseptic technique throughout procedure 7. Sets up supplies 8. Dons personal protective equipment as appropriate for procedure 9. Positions patient 10. Removal procedure: a. Connects syringe into balloon port and removes fluid b. Gently removes old gastrostomy tube c. Verbalizes/demonstrates actions for difficulty removing gastrostomy tube 11. Reinsertion procedure: a. Cleanses stoma site per agency policy/protocol and/or physician orders b. Applies water-soluble lubricant to gastrostomy tube tip and/or stoma c. Gently inserts gastrostomy tube into stoma d. Inflates balloon according to manufacturer s recommendation e. Gently pulls gastrostomy tube so that it rests against the inside of stomach f. If disk present, slides down against skin, allowing sight in and out g. Verifies placement: i. Aspirates for stomach contents ii. Injects air while auscultating for sound h. Applies dressing and securement device as per agency policy/protocol and/or physician orders 12. Cleans equipment/environment post-procedure 13. Provides education to patient/caregiver per assessed needs 14. Maintains safe environment for the patient throughout procedure 15. Utilizes OSHA standards for disposal of hazardous materials and waste 16. Performs hand hygiene according to agency policy/protocol 17. Documents procedure per agency policy/protocol 18. Takes appropriate actions for abnormal findings or observations GASTROINTESTINAL Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 35

NURSING GASTROSTOMY TUBE SITE CARE Scale: 4 = Competent X = Failed NA = Not applicable Scale Procedure 1. Verifies orders 2. Uses two patient identifiers 3. Explains procedure to patient/caregiver 4. Performs hand hygiene according to agency policy/protocol 5. Maintains bag technique per agency policy/protocol throughout procedure 6. Utilizes standard precautions and aseptic technique throughout procedure 7. Sets up supplies 8. Dons personal protective equipment as appropriate for procedure 9. Positions patient 10. Removes old dressing 11. Performs hand hygiene 12. Dons new gloves 13. Observes stoma site 14. Cleanses stoma site per agency policy/protocol and/or physician orders 15. Applies new dressing and securement device as per agency policy/protocol and/or physician orders 16. Cleans equipment/environment post-procedure 17. Provides education to patient/caregiver per assessed needs 18. Maintains safe environment for the patient throughout procedure 19. Utilizes OSHA standards for disposal of hazardous materials and waste 20. Performs hand hygiene according to agency policy/protocol 21. Documents procedure per agency policy/protocol 22. Takes appropriate actions for abnormal findings or observations GASTROINTESTINAL Clinician deemed competent in skill and may perform independently Clinician needs further instruction/observation in competency 37