Would you Hire You?

Write down yes or no for each of the following as they apply to yourself at work.

1. When things go wrong I take my fair share of the blame.

2. Barring illness or accident, I am always at work and ready to go a few minutes before my shift starts.

3. My boss can depend on me to come through in a crisis.

4. My uniform/work attire is always neat, clean and appropriate.

5. I pay attention to personal hygiene.

6. I am courteous and respectful to my coworkers, visitors and managers

7. I am a friendly person

8. I can control my temper

9. I tend to equipment, supplies, work area, etc. to insure it is neat, clean and well maintained

10. I don’t bother with gossip

11. I am in good health

12. I understand I represent my profession as well as my employer (on the phone or in public) and understand the importance of maintaining a professional presentation at all times.



Now score yourself

Give yourself 2 points for every yes and a minus 1 point for every no.

Perfect 24- recheck your responses, no one is perfect

21-23 Get ready for a halo

18-21 Consider yourself an asset to your profession and the company

12-18 Average

Below 12 (50%) You need to improve or find another profession

BE THE TYPE OF PERSON and CO-WORKER YOU WOULD WANT TO WORK WITH

Advanced Directives and Important Information to Help Your Loved Ones

NURSING EDUCATION ACADEMY

Understanding Advance Directives

Q-What are advance directives?

“Advance directives” are legal documents that allow you to plan and make your own end-of- life wishes known in the event that you are unable to communicate. Advance directives consist of a living will and a medical (healthcare) power of attorney. A living will describes your wishes regarding medical care. With a medical power of attorney you will appoint a person to make healthcare decisions for you in case you are unable to speak for yourself.

Q-What is a living will?

A living will is an advance directive that guides your family and healthcare team through the medical treatment you wish to receive if you are unable to communicate your wishes. According to your state’s living will law, this document is considered legal as soon as you sign it and a witness signs it, if your state requires it be witnessed. A living will goes into effect when you are no longer able to make your own decisions.

Q-What is a medical power of attorney?

A medical power of attorney allows you to select a person you trust to make decisions about your medical care if you are temporarily or permanently unable to communicate and make decisions for yourself. This includes not only decisions at the end of your life, but also in other medical situations. This document is also known as a “healthcare proxy,” “appointment of healthcare agent” or “durable power of attorney for healthcare.” This document goes into effect when your physician declares that you are unable to make your own medical decisions. The person you select can also be known as a healthcare agent, surrogate, and attorney-in-fact or healthcare proxy.


Q-Who should I select to be my medical power of attorney?

You should select someone you trust, such as a close family member or good friend who understands your wishes and feels comfortable making healthcare decisions for you. You should have ongoing conversations with this person to talk about your wishes at the end of life. Make sure your medical power of attorney feels comfortable and confident about the type of medical care you want to receive.

Most state laws prevent your doctor or any professional caregiver from being assigned as your healthcare agent. You can also select a second agent as an alternate in case your first healthcare agent is unwilling or unable to serve.


Q-What do I need to know about end-of-life decisions to prepare my advance directive?
Understand life-sustaining treatments

Life-sustaining treatments are specific medical procedures that support the body and keep a person alive when the body is not able to function on its own. Making the decision about whether or not to have life-sustaining treatments can be a difficult decision depending on your situation. You might want to accept life-sustaining treatments if they will help to restore normal functions and improve your condition. However, if you are faced with a serious life-limiting condition, you may not want to prolong your life with life-sustaining treatment.
The most common end-of-life medical decisions that you, family members or an appointed healthcare agent must make involve:
Cardiopulmonary Resuscitation (CPR)
Do Not Resuscitate Order (DNR)
Do Not Intubate Order (DNI)
Artificial Nutrition and Hydration

Q-What is cardiopulmonary resuscitation (CPR)?
Cardiopulmonary resuscitation (CPR) is a group of procedures used when your heart stops (cardiac arrest) or breathing stops (respiratory arrest). For cardiac arrest the treatment may include chest compressions, electrical stimulation or use of medication to support or restore the heart’s ability to function. For respiratory arrest treatment may include insertion of a tube through your mouth or nose into the trachea (wind pipe that connects the throat to the lungs) to artificially support or restore your breathing function. The tube placed in your body is connected to a mechanical ventilator.

Q-What is a Do Not Resuscitate (DNR) order?

A Do Not Resuscitate (DNR) order is a written physician’s order that prevents the healthcare team from initiating CPR. The physician writes and signs a DNR at your request or at the request of your family or appointed healthcare agent if you do not want to receive CPR in the event of cardiac or respiratory arrest.

A doctor must sign the DNR order otherwise it cannot be honored. DNR orders:
1. Can be cancelled at any time by letting the doctor who signed the DNR know that you have changed your decision.
2. Remain in effect if you transfer from one healthcare facility to another. However, consult the arrival facility’s policy to make sure.
3. The DNR may not be honored if you are discharged from the facility to your home if your state does not have an out-of-hospital DNR policy.
4. May not be honored during surgery but this is something very important to discuss with your surgeon and anesthesiologist before surgery so your wishes are honored.
5. Should be posted in the home if that is where you are being cared for.

If there is no DNR order, the healthcare team will respond to the emergency and perform CPR. The team will not have time to consult a living will, the family, the patient’s healthcare agent or the patient’s doctors if they are not present.

Q-What is a Do Not Intubate (DNI) order?
When you request a DNR order, your physician may ask if you also wish to have a “do-not-intubate” order. Intubation is the placement of a tube into the nose or mouth in order to have it enter your windpipe (trachea) to help you breathe when you cannot breathe adequately yourself. Intubation might prevent a heart attack or respiratory arrest. Refusal of intubation does not mean refusal of other techniques of resuscitation. If you do not want mechanical ventilation (breathing), you must discuss intubation because it may be included as part of a DNR order. Even if you have completed a DNR order that does not mean that you have refused to be intubated. If you do not want life mechanically sustained, you must discuss your decision about intubation with your doctor.

Q- What is artificial nutrition and hydration?

Artificial nutrition and hydration are treatments that allow a person to receive nutrition (food) and hydration (fluid) when they are no longer able to take them by mouth. This treatment can be given to a person who cannot eat or drink enough to sustain life. When someone with a serious or life-limiting illness is no longer able to eat or drink, it usually means that the body is beginning to stop functioning as a result of the illness.

Q-How can I prepare my advance directive?

You can fill out a living will and medical power of attorney form without a lawyer. The National Hospice and Palliative Care Organization, your state hospice organization, local hospitals, public health departments, state bar associations or state aging offices provide state-specific forms and instructions. It is very important that you use advance directive forms specifically created for your state so that they are legal. Read the forms carefully and make sure you follow legal requirements determined by your state.

Keep your completed advance directive in an easily accessible place and give photocopies to your primary medical power of attorney and your secondary, alternate agent. This document stays in effect unless you cancel it or decide to complete a new one with changes.

Q- Can healthcare professionals refuse to honor my advance directive?

In some cases there may be a misunderstanding of the law, medical ethics or professional responsibilities. It is important for you to know if your doctor will honor your request. Bring your completed living will to your next healthcare appointment and ask your doctor if he or she has questions or concerns.

Q- Who would decide about my medical care if I did not complete an advance directive?
If you are unable to make decisions, healthcare professionals must consult your family members.

Some states have decision-making laws to identify individuals who may make decisions on your behalf when you do not have an advance directive, such as your spouse, parents or adult children.

Q- Does my advance directive include my wishes about organ donation, cremation or burial?

Some states may include your wishes about whether you want to be an organ donor as part of the advance directive. If it is not included, you can still write down your decision about organ donation. However, you should fill out a specific form for that purpose.
You should also let your loved ones know if you wish to be buried or cremated.


SUGGESTIONS ON STORING YOUR ADVANCED DIRECTIVES
Storing Your Advance Directives
Where you store your advance directives can be just as important as preparing one in the first place. There are many places you can keep the document, but there are a few important factors to consider when deciding where to store:
▪ They must be portable; they can be available wherever you are in the world.
▪ They must be available in a timely manner.
▪ They must be in a safe place, protected from theft, fire, flood or other natural disasters.

Here are some suggestions:
▪ Make several photocopies of the completed documents.
▪ Keep the original documents in a safe but easily accessible place, and tell others where you put them; you can note on the photocopies the location where the originals are kept.

▪ DO NOT KEEP YOUR ADVANCE DIRECTIVES IN A SAFE DEPOSIT BOX. Other people may need access to them.
▪ Give photocopies to your POA for healthcare, healthcare provider and other and representatives.
▪ Be sure your doctors have copies of your advance directives and give copies to everyone who might be involved with your healthcare, such as your family, clergy, or friends. Your local hospital might also be willing to file your advance directives in case you are admitted in the future.

UNDERSTANDING WILLS

A will is a written direction controlling the disposition of property at death.

The laws of each state set the formal requirements for a legal will.

In Florida:You, the maker of the will (called the testator), must be at least 18 years old.
You must be of sound mind at the time you sign your will.
Your will must be written.
Your will should be witnessed and notarized.
There is no legal requirement that dictates an attorney must draft your will, you can find inexpensive help online to complete a do it yourself will

MORE IMPORTANT INFORMATION

Make sure all bank accounts including retirement accounts have designated beneficiaries
Make sure to have a TOD (transfer on death deed) This document allows for transfer of ownership of the home to you designee and can save them thousands of dollars

Make sure to make a funeral declaration. This document records your wishes as far as disposition of your remains. Just telling someone is not enough.

If the above is not done and estate account has to be opened at the bank, everything goes into probate, you need an attorney and essentially the entire process becomes long and drawn not to mention difficult on the heirs.


SORCE for ADVANCE DIRECTIVES
NATIONAL HOSPICE AND PALLIATIVE CARE ORGANIZATION


SOURCE for WILLS and OTHER INFORMATION
FLORIDA BAR

Understanding the Initials of Care Providers

Understanding the Initials

Far more often than you may want to admit patients do not know who is providing their care and sadly some employers bank on this fact to pass off less educated and less costly staff in the guise of licensed professionals.

How many people do you know outside of the healthcare world who really understand a Medical Assistant in the Dr.'s office is NOT  a nurse?  How many lay people do you know that can explain the difference between a NA and RN?

For those within the healthcare realm the initials below will be easily understood but, do you insure that your patients understand who is actually providing care?

Do you consistently make sure your staff wears their badges so they are easily read?  Do you make sure every staff member understands the importance of introducing themselves with their proper title and simple explanation of their role?  Do you take a moment to educate people on the different roles helping them to understand the education, licensing requirement, etc. of each role they may encounter while in the healthcare system?

A Short list of some various roles:

MD, DO, ARNP, RN, LPN, LVN, PA, SA, PCT, EMT, EMT II, CNA, STNA, MA, HHA, RNFA, CST, CRNA


Some basics:

It is imperative that you understand what your team members may or may not do.

Each state in the U.S. has written laws as to which titles they recognize, the education requirement for each title and if there are license or certification requirements. If the state does not regulate or establish guidelines for a particular working title then usually that job title will be guided by standards from those who reimburse for payment such as Medicare and Medicaid.

For example, some states do not regulate the MA or SA (Medical assistant, Surgeon’s assistant). Therefore, a physician could hire anyone they wish and train them on site. Some states do not regulate the HHA but the hiring agency would implement guidelines so their staff follows established guidelines as needed so they will be reimbursed by insurance companies, Medicare, Medicaid, etc.
Some states require a minimum of an A.S. degree to be a paramedic while other states allow certification programs and use the title EMT II.

YOU are responsible to read the laws and understand them. If you are a manager, supervisor, MD, DO, RN (including any advanced practice RN) or LPN/LVN you must be knowledgeable of what duties members of the allied health team may provide and what their qualifications must be.

If you are the patient or a family member, you have every right to ask and understand who is providing care. For example, DO NOT assume just because someone wearing a white coat or is in scrubs in the ER is a Doctor. Far more often than not it will be a paramedic and PA, ARNP, RN.

Staff members must wear a clearly visible ID badge that clearly indicates their name and title.

Let’s decipher some of the abbreviations.
This list is not all-inclusive

MD- Medical Doctor
Initial 4 years of college to earn the basic MD then additional years as resident/intern thus this is a Master level education

DO- Doctor of Osteopathic Medicine
Initial 4 years of college to earn the basic DO then minimum of two years residency thus this is a Master level education

ARNP- Advanced Registered Nurse Practitioner
Initial 4 years to earn BSN then minimum of two years for advanced practice specialty thus this is a Master level education.

RN- Registered Nurse
Entry into the profession can be earned via an AS or BS degree in nursing however many states and facilities mandate a BSN (Bachelor of Science in Nursing) for entry into the profession

LPN- Licensed Practical Nurse
9 month vocational training program.

LVN- Licensed Vocational Nurse
9 month vocational training program

PA- Physician’s Assistant
Entry into the profession can be via an AS or BS degree from an accredited college program.  

SA- Surgeon’s Assistant
Some states require the SA earn at least an AS in surgical technology with national certification prior to working while other states have no regulation thus allowing a surgeon or office manager to hire anyone they wish and train them without regard to education, character or criminal history.

EMT- Emergency Medical Technician
Each state regulates entry into practice requirements.  Some states accept Vocational training with certification while other states mandate an AS degree with certification.  There's various levels of EMT which can include EMT I, EMT II, A-EMT.  Each level requires further training and expertise so the caregiver can provide more in depth care.

PCT- Patient Care Technician
Some states use this title rather than NA or STNA.  Entry into the workforce can be via a vocational training program or it can be via a facility based training program.  Some programs are a few weeks in length while others may be a few months.

CNA- Certified Nursing Assistant (STNA- State Tested Nursing Assistant)
The Federal OBRA laws of the 1970's mandate that all NA's be state certified with a minimum of 72 hours of training.

MA- Medical Assistant
Some states require the MA earn at least an AS and be nationally certified while other states have no regulation thus the doctor or office manager can hire anyone without regard to education, character or criminal history and office train them.

HHA- Home Health Aide
Many states do not have laws that mandate certification for this role however in order for a Home Health Agency to receive reimbursement from insurance companies and/or medicare the HHA must be certified.  In most states, in order to become a certified HHA the applicant must first earn the state certification as a NA and prove a minimum of one year facility experience as a NA.

RNFA- Registered Nurse, First Assistant
One must first be a RN who has earned the CNOR (Certified Nurse - Operating Room) and have completed an accredited RNFA program and national exam.  As of 2020 the RN must be earned at the BSN level which will then indicate this professional title will be held at the Master level

CST- Certified Surgical Technologist (Scrub Tech)
Some states require the CST earn an AS degree in Surgical Technology and the national certification exam in order to work as a scrub tech in surgery

CRNA-Certified Registered Nurse Anesthetist
Initial RN license is required prior to education at the Master level to earn the CRNA license

For more information and more job titles take a look at the Bureau of Labor Statistics Occupational Handbook

http://www.bls.gov/ooh/healthcare/home.htm

CAREGIVER AGREEMENTS AND MEDICAID

CAREGIVER AGREEMENTS AND MEDICAID
As our elders begin to need assistance with activities of daily living, usually it is a family member that helps provide these services. Generally, the family member assumes the responsibility of taking care of the aging parent or grandparent out of love or a sense familial responsibility. As such, generally no financial arrangement is in place and the adult child or family member provides these services for free.


THE ‘LOOK BACK’ RULE FOR MEDICAID

The Deficit Reduction Act of 2005 changed the Medicaid “look back” on all gifts from 3 years to 5 years. As a result, individuals concerned about Medicaid eligibility, personal service contracts where a “caregiver” charges for the services provided to their elderly family member have grown in popularity. Payments to family members for services provided are not considered gifts subject to a transfer penalty or the ‘Look Back Rule’ in determining Medicaid eligibility. Services provided can be, but are not limited to:

· paying bills

· shopping

· preparing meals

· making sure the proper medication is taken at the appropriate time

· arranging doctors visits

· accompanying to doctor visits

· transportation

· household chores

· personal hygiene and dressing assistance



THE CONTRACT MUST STATE FAIR LABOR RATES In order for a Personal Services Contract to be accepted by the local Medicaid office it must include certain safeguards:

· Fair Market Compensation must be charged and stated in the contract. So that Medicaid can confirm what services will be provided, credible documentation must be maintained. The service provider, usually a relative, should keep a log of dates, times and services provided.



· The service provider may research the U.S. Department of Labor, Bureau of Labor Statistics, and Occupational Outlook Handbook to assist them in determining the fair market value of services provided. The latest edition can be found online at http://www.bls.gov/oco/ . Personal care services rates can range from $18-$22 an hour and geriatric-care management services from $60-$150 an hour.

· The service provider can either be paid (1) in a lump sum transfer in exchange for services to be provided to the family member for the lifetime of the applicant, or (2) on an hourly or weekly salary rate.

· If the personal services contract is paid by lump sum in advance, the contract must have a provision that provides for the return of any prepaid monies if the caregiver becomes unable to perform the specified duties or the elderly individual passes away prior to the calculated life expectancy in arriving at the lump sum amount.

· The personal services contract cannot state services will be provided on an “as needed basis” because there is no way to validate the fair market value of such services. As stated previously, the services to be provided should be clearly identified, and the amount of days and hours clearly stated.

· No services can be provided while the individual is under the care of a nursing home. Additionally, there can be no duplication of services should a home health aide or other care provider be hired.


INCOME TO THE PROVIDER Caregivers/Service Providers must pay applicable federal, state and employment taxes on the income earned.


CONCLUSION Personal Service Contracts can be a valuable tool in minimizing an aging family member’s estate. Strict formalities must be met, and the service contract cannot be for past services already rendered. A detailed written agreement must be in place before the services start. For assistance in drafting a caregiver agreement and determining a fair market rate of services either weekly or lump sum, please contact this office.



For informational purposes only. Be sure to check with your attorney or financial advisor as well as your state’s Medicaid rules. 

Nursing Is ...By dcs

"Nursing is an art and science; it is a calling not simply a job, it is heart and intelligence blended in a perfect recipe that yields compassion and empathy. Each and every day your hands, heart and mind sculpt the most beautiful art works known to man."~dcs

Nurses Code of Ethics

"Nursing is an art and science; it is a calling not simply a job, it is heart and intelligence blended in a perfect recipe that yields compassion and empathy. Each and every day your hands, heart and mind sculpt the most beautiful art works known to man."~dcs

Nurses Code of Ethics:
1. The nurse provides services with respect for human dignity and the uniqueness of each client
2. The nurse safeguards the client's right to privacy
3. The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical or illegal practice of any person.
4. The nurse assumes responsibility and accountability for individual nursing judgement and actions.
5. The nurse maintains competence in nursing
6. The nurse exercises informed judgement and uses individual competence and qualifications
7 The nurse participates in activities that contribute to the ongoing development of the profession's body of knowledge
8 The nurse participates in the profession's efforts to implement and improve standards of nursing.
9 The nurse participates in efforts to establish and maintain employment conducive to high quality nursing care
10 The nurse participates in the profession's effort to protect the public