3. Ethics in healthcare.

  • Essential functions of the health care facility and the differences between acute, long-term, assisted living, home care and hospice.

            Acute care is a branch of secondary health care where a patient receives active but short-term treatment for a severe injury or episode of illness, an urgent medical condition, or during recovery from surgery. In medical terms, care for acute health conditions is the opposite from chronic care, or longer term care.       

            Long term care refers to a continuum of medical and social services de- signed to support the needs of people living with chronic health problems that affect their ability to perform everyday activities. Long term care services include traditional medical services, social services, and housing.

            Assisted living   is a system of housing and limited care that is designed for senior citizens who need some assistance with daily activities but do not require care in a nursing home.

            Home care, (also referred to as domiciliary care, social care, or in-home care), is supportive care provided in the home.

            Rehabilitation: The process of helping a person who has suffered an illness or injury restore lost skills and so regain maximum self-sufficiency. For example, rehabilitation work after a stroke may help the patient walk and speak clearly again.

            Hospice care: Care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure.

    Home Care

            Home care is becoming an increasingly viable and attractive alternative to facility-based long-term care (nursing homes and assisted living), and it is only expected to grow in popularity as baby boomers age. Home care covers a wide range of services for individuals who require ongoing healthcare and assistance with the activities of daily living. When family and friends cannot provide adequate support, home care allows people to receive the care they need to remain in their homes.

            The individuals who receive home care may be elderly, disabled, terminally or chronically ill, or they may be recovering from surgery. While the majority of individuals receiving home care are over the age of 65, home care consumers may be any age, beginning with infants who may need ventilators or other care in order to live at home. Home care agencies deliver services through physicians, nurses, therapists, social workers, home health and personal care aides, and volunteers.

            Home care may include health-related services such as injections, intravenous therapy, and wound care. It may include assistance with personal care, such as getting in and out of bed, walking or mobility, bathing, using the toilet, and dressing, and it may also include assistance with household tasks, such as laundry, meal preparation, general housekeeping, and shopping.

            Home care services may be paid for by an individual or family member, by health insurance companies, managed care organizations, the Veteran’s Administration, community organizations, Social Services Block Grants, Medicare, Medicaid, and other sources.

            Most states license home care agencies, but licensure requirements vary widely from state to state. Forty-four states, including Colorado, require a license for agencies that provide home health services (e.g., medication administration, injections, intravenous therapy, and wound care), and 30 states, including Colorado, additionally require a license for agencies that provide personal care services. In order to receive funds from Medicare and Medicaid, home care agencies must meet minimum federal standards.

    Colorado licenses two types of home care agencies

            Class A and Class B. Only Class A agencies may provide home health services.

            Both Class A and Class B agencies provide assistance with personal care, medication reminders, companionship, and homemaking services.

  • Colorado State Regulations, Summary of Current Laws.

    Colorado State Regulations.

            History of Regulation In 2008, the General Assembly passed Senate Bill 08-153 (SB 153), which required home care agencies to be licensed by the Health Facilities and Emergency Medical Services Division (Division) in the Colorado Department of Public Health and Environment (CDPHE) and charged the Colorado State Board of Health (Board of Health) with adopting rules for the licensing program. The purpose of regulation was to address a growing concern regarding the provision of care by home care agencies, specifically improper patient care and criminal activity.

            Although individuals could be prosecuted for fraud or abuse of patients, privately funded home health agencies could not be removed from the marketplace since they were not regulated, and serious problems were found in home care agencies that were certified as Medicare and Medicaid providers.

            The bill required home care agencies to ensure that their employees were adequately trained and vetted. Senate Bill 153 also required home care placement agencies1 (placement agencies) to register with the Division. It required placement agencies to perform criminal history record checks in order to refer individuals to provide skilled health and personal care services2 in the home, and they were also required to provide a disclosure to consumers concerning the duties and employment status of the individual providing services.

            In 2010, the General Assembly passed Senate Bill 10-194 (SB 194), which placed a moratorium on the licensure requirement for Community Centered Boards (CCBs) and agencies that provide services to persons with developmental disabilities. This moratorium expired in March 2011. Senate Bill 194 also exempted qualified early intervention service providers for children with developmental disabilities. In 2012, the General Assembly passed House Bill 12-1294, which impacted the regulation of all health facilities in Colorado. Specifically, it required the Board of Health to establish different requirements appropriate to the various types of home care agencies, such as those that are substantially funded through Medicare or Medicaid and Providers of All-Inclusive Care for the Elderly.

                    a)    Home care placement agencies provide referrals for home care attendants, for a fee, and do not employ or contract with home care attendants.

                    b)    Personal care services include, but are not limited to, getting in and out of bed, walking or mobility, bathing, using the toilet, and dressing.

    Summary of Current Laws

            Licensing Home care agencies are required to be licensed by the Division in order to provide skilled home health services and personal care services to consumers in their homes.

            The Board of Health housed in CDPHE is charged with adopting rules for licensing home care agencies.

    A home care agency is defined as

            Any sole proprietorship, partnership, association, corporation, government or governmental subdivision or agency […], not-for-profit agency, or any other legal or commercial entity that manages and offers, directly or by contract, skilled home health services or personal care services to a home care consumer in the home care consumer’s temporary or permanent home or place of residence. A residential facility that delivers skilled home health or personal care services which the facility is not licensed to provide shall either be licensed as a home care agency or require the skilled home health or personal care services to be delivered by a licensed home care agency.

    Skilled home health services are defined as

            Health and medical services furnished to a home care consumer in the home care consumer’s temporary or permanent home or place of residence that include wound care services; use of medical supplies including drugs and biologicals prescribed by a physician; in-home infusion services; nursing services; home health aide or certified nurse aide services that require the supervision of a licensed or certified healthcare professional acting within the scope of his or her license or certificate; occupational therapy; physical therapy; respiratory care services; dietetics and nutrition counseling services; medication administration; medical social services; and speech-language pathology services. “Skilled home health services” does not include the delivery of either durable medical equipment or medical supplies.

    Personal care services are defined as

            Assistance with activities of daily living, including but not limited to bathing, dressing, eating, transferring, walking or mobility, toileting, and continence care. It also includes housekeeping, personal laundry, medication reminders, and companionship services furnished to a home care consumer in the home care consumer’s temporary or permanent home or place of residence, and those normal daily routines that the home care consumer could perform for himself or herself were he or she physically capable, which are intended to enable that individual to remain safely and comfortably in the home care consumer’s temporary or permanent home or place of residence.5

                  1 § 25-27.5-103(1), C.R.S

                  2 § 25-27.5-104(1), C.R.S.

                  3 § 25-27.5-102(3) (a), C.R.S.

                  4 § 25-27.5-102(7), C.R.S.

                  5 § 25-27.5-102(6), C.R.S

            The Colorado State Board of Health (Board of Health) is vested with the authority to adopt rules for home care agencies and placement agencies. The Board of Health sets the minimum standards for the operation of home care agencies. The Division licenses two types of home care agencies:

    • Class A agencies provide skilled healthcare services (e.g., medication administration, injections, intravenous therapy, and wound care), personal care services (e.g., getting in and out of bed, walking or mobility, bathing, using the toilet, and dressing), and other services such as homemaker and companion services.
    • Class B agencies provide personal care services and other services such as homemaker and companion services. However, they are not licensed to provide skilled healthcare services.
    References: DORA (Department of Regulatory Agencies).

            When is Skilled Care required?

              1. General prohibitions:

                   a)    Broken skin or inactive skin problems, wound care.

                   b)    Use of prescription ointments, stocking, exercise.

                   c)    When client is not independent with eating, chewing, swallowing, or at risk of chocking and aspiration.

                   d)    Medications, suppositories.

                   e)    Catheters, enemas.

                   f)     Respiratory care, except to move mask to shave client.

                  g)    When client’s condition: Requires reports to nurse. Involves circulatory problems, loss of sensation.

            2. When is personal Care appropriate?

                  a)    As a medical condition improves and less assistance is required for functional mobility.

                  b)    Companionship needs.

                  c)    When client fully trained with adaptive equipment.

                  d)    When client fully trained, only needs stand by assist.

                  e)    Client does not required skilled transfer.

                  f)     Medication reminding, assistance OK when pre-poured /prepared, well labeled and complete instructions re time.

    (Use list 6CCR1011-1 section7, section 8).

  • Regulatory and professional guidelines.

    Standards of conduct:

            A code of conduct is a set of rules outlining the social norms and rules and responsibilities of, or proper practices for, an individual, party or organization. Related concepts include ethical, honor and moral codes, as well as halachic and religious laws.

    Ethics in the workplace:

            Workplace ethics and behavior are a crucial part of employment, as both are aspects that can assist a company in its efforts to be profitable. In fact, ethics and behavior are just as important to most companies as performance as high morale and teamwork are two ingredients for success. Every business in every industry has certain guidelines to which its employees must adhere, and frequently outline such aspects in employee handbook.

    Informed consent:

            Informed consent is a permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.

            Quality Management Plan: Every licensed or certified facility shall establish a Quality management program appropriate to the size and type of facility that evaluates the quality of patient or resident care and safety, and complies with rules and regulations.

            Personnel Management Recruitment/hiring. Advertising, screening, reference check, back ground checks, orientation, continuing education, supervision, scheduling.

    Professional work habits and time management skills:

            Time management is the act or process of planning and exercising conscious control over the amount of time spent on specific activities, especially to increase effectiveness, efficiency or productivity.


    PCW Daily Jobs and time management.

            A Personal care worker may be responsible for providing a safe, clean living area for the care recipient. The extent of these home services will depend on the needs of the loved one. A clean environment keeps harmful bacteria under control and helps stop the spread of communicable diseases. It also makes one feel more relaxed and comfortable, and is, therefore, conducive to the good health of the care recipient. Food stored properly and spills wiped up promptly keep insects from becoming a problem. Clean rooms provide an orderly way of living, enable us to find things easily, and help prevent accidents. It may be helpful to set up a daily work plan for the jobs that family members can follow. Always make a list of what you need to keep a living area clean, and use those products already in the home where possible. Before beginning your tasks, collect all supplies and equipment needs for a chore and carry them in a pail, tray, shopping bag, or laundry basket from one room to another. Carry a pad and pencil for noting items that need to be bought or replaced. Plan major jobs for different days of the week – i.e. don’t do laundry, vacuuming, and wash floors all on the same day.


            Dusting helps prevent the spread of bacteria. It also helps those who are sensitive to dust. Dusting should be done daily or at least weekly. Lightly dampen a rag with water or a commercial spray to keep the dust from spreading. Move the cloth to gather the dust onto it.


            Floors Rugs and carpets should be vacuumed or swept regularly. Furniture may have to be moved to do a proper job. Smaller rugs can be shaken and washed. Do not wash wood floors. Instead, vacuum and clean with a vinegar/water solution or use a commercial product. Hard floors can be swept or vacuumed and mopped. Always mop tile or linoleum floors with a well wrung-out mop or rag so as not to loosen the tiles or make them slippery. Small rugs placed in entryways can catch a lot of dirt from the outside.

    Washing Dishes:

            Proper dishwashing kills bacteria. Always wash dishes as soon after a meal as possible. When using a dishwasher, first scrape and rinse the dishes. Load the dishwasher and run it when you have a full load to conserve water and electricity. If you don’t have a dishwasher, wash and rinse dishes by hand. Wash the cleanest dishes first and the dirtiest last (glasses and cups, silverware, plates, pots and pans.) Rinse dishes well and place in drain board or on towel. Allow them to air dry if possible.

    Cleaning the Kitchen:

            A kitchen is cleaned more frequently than any other room in the home. You should clean up after each meal to kill as many bacteria as possible. Keeping a kitchen clean and tidy is easy if you remember to do each of these chores:

    1. Refrigerate or otherwise store all food immediately after each meal.
    2. Clean up any spills regularly, especially on a stove where they can become baked on.
    3. Wipe out the refrigerator regularly, defrosting when necessary.
    4. Wipe down any small appliances with soap and water. Remember to disconnect them first.
    5. Wipe off the countertops, areas around the drawer handles, and door pulls. Keep surfaces uncluttered.
    6. Wash, rinse, drain, and put away all dishes as soon as possible after each meal.
    7. Scrub cutting boards between and after each use.
    8. Mop the floors and take out any garbage.
    Cleaning the Dining and Living rooms:
    1. Clean up crumbs under and around table.
    2. Tidy up.
    3. Throw out recycle newspapers.
    4. Empty ashtrays and wastebaskets.
    5. Dry-mop floor.
    6. Dust furniture and window sills.
    Cleaning the Bathroom:

            Bathrooms usually have constant moisture in the air. Therefore, they need to be cleaned regularly to kill bacteria and odors. Water left on the floor can be slippery and dangerous. When you clean a bathroom, make a point of doing the following:

    1. Wipe out the shower/tub after each use.
    2. Clean sinks and other fixtures regularly.
    3. Clean the toilet:

                   a) Scrub the toilet bowl with soap or detergent, especially under the rim.

                   b) Leave the suds in the bowl while you wash the outside.

                   c) Do NOT mix toilet bowl cleaner with other cleansers.

                   d) Use clean, hot water to rinse off the toilet.

          4. Mop the floors or vacuum the carpet.

                  a) Use care when scrubbing.

                  b) Change cleaning water when moderately dirty.

                  c) Rinse if needed to avoid streaking or filming.

                  d) Store all cleaning products safely. They should be kept in their original containers, away from children, pets, and any heat sources. Cleaning tools and supplies should be stored safely as close as possible to where you will use them.

    Cleaning the Bedroom:
    1. Put clothes away or into wash.
    2. Straighten room and empty trash.
    3. Dry-mop or vacuum floor.
    4. Air out beds and make them up

            Your care recipient may spend part of or all of the day in bed. As a result, many individuals are fed, bathed, and use the bedpan in bed. Making a bed properly is, therefore, very important. A clean, neat bed will make the care recipient comfortable. Wrinkles are uncomfortable and restrict the circulation, and can cause pressure sores (decubitus ulcers). Make the bed wherever your care recipient has decided to sleep, whether in bed or on the couch. Use whatever linens are in the house. .

    There are three basic types of beds:
    1. Closed bed – used when the bed will be empty for a while. It will stay clean, not exposing the linens.
    2. Open bed – used when the care recipient is out of bed for a while but needs to get into it easily. The top sheet of the closed bed is fan-folded down.
    3. Occupied bed – used when the bed is made with the care recipient in it and not able or permitted to get out of the bed.
    Tips for bed making:
    1. Keep the bed dry and clean. Change linens when needed.
    2. Keep the bed wrinkle-free.
    3. Keep the bed free of food and crumbs.
    4. Make the bed to suit your care recipient.
    Bed Linen
    Folding Flat and Fitted Sheets
    •    › Show respect and consideration for client preferences. Solicit their input.
    •    › Fold sheets promptly while still hot from the dryer to minimize wrinkling.
    •    › Exercise careful folding. Smooth on a flat surface to minimize wrinkling.
    •    › Fold lengthwise by carefully matching ends.
    •    › Fold widthwise, smoothing wrinkles. Fold to achieve a compact, rectangular shape (4-6 folds total).
    •    › With fitted sheets, mimic flat sheet method. Place one fitted corner into the opposite corner. Keep as flat as possible.
    •    › Repeat as necessary to achieve an approximate rectangular shape to match the flat sheet.
    •    › Fold lengthwise into rectangular shape (4-6 folds total).
    Hints on Bed-Making
    •    › Respect client wishes. Note client limitations.
    •    › Ensure bottom fitted or flat sheet is snug, secure, and wrinkle-free.
    •    › Place the top sheet according to client preference.

            Well-centered from side to side, adequate length at head of bed, adequate length of sheet at foot of bed for proper tucking Hospital corners – then secure or leave loose as preferred.

    •    › Bottom sheet, then optional water-resistant pad (“Chucks”), and draw sheet for client with bladder-control problems.(optional).
    •    › Pleat or fold in center foot of top sheet (optional) to relieve pressure on feet.
    Linen Change Procedure:
    1.    Plan ahead.
    2.    Keep clean linen on a clean surface, separate from soiled linen.
    3.    If linen is soiled with body fluids, WEAR GLOVES.
    4.    Loosen linens on the bed. Remove them, folding the cleaner areas over the stained area
    5.    Complete the linen change.
    6.    Hold soiled linens away from clothing. Avoid shaking or fanning the linens.
    7.    Place dirty linens in designated area (hamper, dirty pillowcase, laundry basket, etc.), or launder immediately in the family’s washing machine.
    8.    Remove and discard gloves if used.
    9.    Wash hands.
    Seasonal Bedding Changes:
    1.    Offer assistance with winter/summer bedding changes. Launder blankets per label/client instruction prior to storage.
    2.    Ensure placement of electric blanket to avoid direct contact with client’s skin.
    3.    Place electric blanket controls in easy to reach location.
    4.    Elderly are at increased risk for hypothermia. Be sure there are adequate, easily available, additional blankets.
    1.    Clean out refrigerator. Wash inside and out before doing weekly marketing.
    2.    Give the stove thorough washing inside and outside.
    3.    Clean appliances such as the microwave.
    4.    Scrub the floor with hot, sudsy water. Rinse with hot water or as client directs.
    5.    Grocery shopping – as directed
    1.    Scrub toilet bowl with toilet brush and toilet bowl cleaner.
    2.    Wash outside toilet surfaces with disinfectant.
    3.    Wash the mirrors.
    4.    Make sure there is enough soap in each soap dish.
    5.    Launder the bath mat and bathroom rug.
    6.    Scrub the shower stall.
    7.    Wipe shower curtain with a weak mixture of bleach and water.
    1.    Open the closet doors to air out clothes.
    2.    Put clean sheets and pillowcases on the beds.
    3.    Change or wash the mattress covers or waterproof pads if they are soiled.
    4.    Vacuum or use slightly damp mop to dust bare floors.
    5.    Use cloth squeezed in hot, sudsy water to clean fingerprints off walls, woodwork, and light switches.
    6.    Dust furniture, light fixtures, lamps, books, windowsills, phone, and small items.
    Dining room
    1.    Sweep or vacuum carpet or rug
    2.    Vacuum or clean bare floors with slightly damp mop
    3.    Use cloth squeezed in hot, sudsy water to clean fingerprints off walls, woodwork, and light switches.
    4.    Dust the furniture, light fixtures, any open shelves, ornamental china, glassware or sliver, as client directs.

    (Respect Client wishes and directions)

    1.    Defrost freezer
    2.    Clean and organize cupboards and drawers.
    3.    This is a good time to discuss with client any stored food.
    4.    Wash cabinet doors with soapy water, or as recommended by client
    5.    Dust light fixtures, clean oven vent and hood as needed.

            Perform organizational tasks; straighten medicine chest or closet.

    1.    Offer to clean or organize closets or drawers.
    2.    Take clothes to dry cleaner if necessary.
    3.    Vacuum under bed and furniture
    4.    Wash baseboards & windowsills.
    5.    Vacuum under furniture
    6.    Dust light fixtures or wash with warm soapy water.

    Be careful not to burn yourself!

    1.    Use vacuum attachments or CLEAN broom or mop to remove cobwebs from ceiling and walls.
    2.    Windex pictures if requested by client.
    3.    Dust phone or wipe with warm water or disinfectant as needed.
    4.    Dust plants, if desired by client.

            Monthly tasks take time away from your ordinary routine.

            You will need to plan ahead with your client and take about ten minutes out of each visit to accomplish them.

  • Stress management techniques.

    Recognize warning signs of excessive stress at work

            When you feel overwhelmed at work, you lose confidence and may become irritable or withdrawn. This can make you less productive and less effective in your job, and make the work seem less rewarding. If you ignore the warning signs of work stress, they can lead to bigger problems. Beyond interfering with job performance and satisfaction, chronic or intense stress can also lead to physical and emotional health problems.

    Signs and symptoms of excessive job and workplace stress:
    • Feeling anxious, irritable, or depressed
    • Apathy, loss of interest in work
    • Problems sleeping
    • Fatigue
    • Trouble concentrating
    • Muscle tension or headaches
    • Stomach problems
    • Social withdrawal
    • Loss of sex drive
    • Using alcohol or drugs to cope
    Taking Steps to Manage Stress
    • Track your stressors. Keep a journal for a week or two to identify which situations create the most stress and how you respond to them. Record your thoughts, feelings, and information about the environment, including the people and circumstances involved, the physical setting and how you reacted. Did you raise your voice? Get a snack from the vending machine? Go for a walk? Taking notes can help you find patterns among your stressors and your reactions to them.
    • Develop healthy responses. Instead of attempting to fight stress with fast food or alcohol, do your best to make healthy choices when you feel the tension rise. Exercise is a great stress-buster. Yoga can be an excellent choice, but any form of physical activity is beneficial. Also, make time for hobbies and favorite activities. Whether it’s reading a novel, going to concerts or playing games with your family, make sure to set aside time for the things that bring you pleasure. Getting enough good-quality sleep is also important for effective stress management. Build healthy sleep habits by limiting your caffeine intake late in the day and minimizing stimulating activities, such as computer and television use, at night.
    • Establish boundaries. In today’s digital world, it’s easy to feel pressure to be available 24 hours a day. Establish some work-life boundaries for yourself. That might mean making a rule not to check email from home in the evening, or not answering the phone during dinner. Although people have different preferences when it comes to how much they blend their work and home life, creating some clear boundaries between these realms can reduce the potential for work-life conflict and the stress that goes with it.
    • Take time to recharge. To avoid the negative effects of chronic stress and burnout, we need time to replenish and return to our pre-stress level of functioning. This recovery process requires “switching off” from work by having periods of time when you are neither engaging in work-related activities nor thinking about work. That’s why it’s critical that you disconnect from time to time, in a way that fits your needs and preferences. Don’t let your vacation days go to waste. When possible, take time off to relax and unwind, so you come back to work feeling reinvigorated and ready to perform at your best. When you’re not able to take time off, get a quick boost by turning off your smartphone and focusing your attention on non-work activities for a while.
    • Learn how to relax. Techniques such as meditation, deep breathing exercises and mindfulness (a state in which you actively observe present experiences and thoughts without judging them) can help melt away stress. Start by taking a few minutes each day to focus on a simple activity like breathing, walking or enjoying a meal. The skill of being able to focus purposefully on a single activity without distraction will get stronger with practice and you’ll find that you can apply it to many different aspects of your life.
    • Talk to your supervisor. Healthy employees are typically more productive, so your boss has an incentive to create a work environment that promotes employee well-being. Start by having an open conversation with your supervisor. The purpose of this isn’t to lay out a list of complaints, but rather to come up with an effective plan for managing the stressors you’ve identified, so you can perform at your best on the job. While some parts of the plan may be designed to help you improve your skills in areas such as time management, other elements might include identifying employer-sponsored wellness resources you can tap into, clarifying what’s expected of you, getting necessary resources or support from colleagues, enriching your job to include more challenging or meaningful tasks, or making changes to your physical workspace to make it more comfortable and reduce strain.
    • Get some support. Accepting help from trusted friends and family members can improve your ability to manage stress. Your employer may also have stress management resources available through an employee assistance program (EAP), including online information, available counseling, and referral to mental health professionals, if needed. If you continue to feel overwhelmed by work stress, you may want to talk to a psychologist, who can help you better manage stress and change unhealthy behavior.