Care plans, client transfers, infection control, violence in home health care setting, liability risks.

3. Care Plans, Client Transfers, Infection Control, Violence In Home Health Care Setting, Liability Risks.

Care Plans.

        Care plans are the roadmap to delivering effective, caring and safe services to clients. Pre-planning, doing appropriate assessments, developing the plan and documenting the flow of the plan translate not into not just business sense, but potentially saving the organization from major financial loss.

        While the format and specifics may vary based on the type of client or customer served, accreditation and regulatory requirement, care plans generally need to address:

  • Diagnosis
  • Allergies
  • Physician orders and treatment plans
  • Past medical history
  • Medical provider contact information
  • Frequency of visits
  • Correspondence between the physician and the family
  • Drug handling procedures
  • Properly completed informed-consent forms

        Home care workers often work alone in environments they do not control. Client transfer tasks may be complicated by confines spaces and inaccessible or difficult to negotiate areas of the home. Workers are likely to encounter situations where there are no mechanical transfer devices and clients may prefer to use their own beds rather than powered and/or adjustable hospital beds. Physical handling required to assist in daily activities of living may be frequent, requiring a wide variety of postures. Client sizes are increasing and a higher percentage of the population is electing to or being forced to stay in the home. Clients may be instable, combative, agitated or confused.

        The overwhelming majority of home care workers are female, and the population of workers in this field is aging. Workers may also be unaware of opportunities to access and the availability of mechanical transfer devices. In some areas and companies, many workers, and even employers, in the profession follow the philosophy of “we transfer patients this way because that’s the way it’s always been done.”.

        In addition to client transfers, the home care worker may assist with other activities of daily living, such as cooking, cleaning, shopping and laundry. These activities can contribute to cumulative physical stress and in some cases, may be more hazardous than patient handling.

        Risk Transfer:

        If an organization is willing to accept the risk of transferring clients, there need to be parameters established as to who will be transferred and under what circumstances. Are there clients with specific physical or cognitive limitations or disabilities that the organization does not wish to transfer? What does “transfer mean?” Specific transfer specifications should be carefully outlined in the client care plan. Are transfers considered things such as to/from beds, wheelchairs, bathtubs, automobiles?


        Engineering involves the use of equipment to reduce the risk of injury to the client or the employee from primarily lifting and handling or trips and falls. Some of the more common engineering controls in the field of home healthcare include:

  • Mechanical Lifts – Mechanical lifts take many forms dependent on the client and circumstances of the transfer. These include full body lifts, lifts to assist in transferring the client who has some mobility and ambulation lifts help to support the client while walking.
  • Trapeze bars – A trapeze bar allows the client to grasp and position themselves in bed or to help when they are being transferred.
  • Gait belts – are the most frequently used client transfer tool in the industry. In its most basic form, the belt is a towel wrapped around the client’s waist. More commonly, these are made of canvas. Transfer belts are wider and have handles on each side for better control.
  • Slip sheets or transfer sheets – can be thin, plastic boards or heavy cotton linens placed under the patient to slide them horizontally or to help in positioning in beds or chair.
  • Pivot discs – many injuries suffered by nursing, CNAs and other healthcare personnel are injuries to the knees while transferring patients from beds to/from wheelchairs and wheelchairs to/from toilets. When shoes and floor surfaces combine to limit the ability to pivot, significant stress can be placed on the knees. The pivot disk, placed at the point of transfer, permits easy pivoting and reduces stress on the back.

        Of all the engineering controls listed, none except the full body mechanical lift eliminates physical stress. Other than the full body lift, any client transfer task places the homecare worker at risk from either a traumatic injury, or injury as a result of cumulative injury over time.


        Slips, trips and falls are the second leading cause of injury to home care workers. They happen when walking to the patient’s home, when negotiating through the home and most frequently while providing assistance to the patient.

      Prevention and Control:

        Because the home care worker does not control the environment they work in, it is often difficult to “engineer out” the potential sources of injury. As with client transfers, there are measures that can significantly reduce the potential for injury.

        Home assessments can be helpful in identifying slip, trip and fall hazards for the prospective new customer. Identification of hazards and requirements to make corrections before accepting the client as a client are not necessarily the easiest solution, but are the best answer. These assessments are necessary at least informally at every visit.

        Proper slip resistive footwear goes a long way in preventing slips and falls on wet and snowy surfaces. In heavy show or where ice is present, consider ice cleats for shoes and keeping small amounts of sand in the car. Keep floors clean and dry.

       Look specifically for:
  • Large cracks or holes in the walkway;

        During winter months, are the walkways cleared? This needs to be a requirement in the contract and there needs to be a plan for dealing with the situation if it is not (refuse to do the work, carry equipment and materials to deal with the situation or arrange for another party to clear the way);

  • Steps and stairs need to be sound and sturdy. Watch especially for railings. Are they firmly anchored and secure?

        Ponding water can create serious accumulations of ice. Do workers need to walk in areas where this occurs?

        If services will be provided during hours of darkness, is lighting adequate from where they park to the doorway?


        According to the World Health Organization, approximately 6% of healthcare workers experience a potential exposure to infectious disease annually. These include almost 400,000 sharps injuries annually to hospital based personnel alone in the U.S. (CDC) Any use of needles, scalpels, scissors or handling bodily fluids exposes workers to over 20 types of pathogens, including hepatitis B&C and HIV. While some contagions present a higher risk than others for transmission (up to 10% for HCV from a single needle stick,) any exposure carries a risk. For some injectables, the medicine itself can be hazardous to the healthcare worker if they inadvertently inject themselves. In home care, even where injections are not given by the worker or other activities exposing the worker to bodily fluids, there may still be exposure from patient administered drugs and when disposing of trash, handling laundry, soiled patient care equipment and other sources.

  • Safety equipped injection devices, training and education, alternative ways of administering medication
  • Educate employees about the dangers of potential punctures and blood borne pathogens, how to prevent them, reporting when they occur and describing what happens after an exposure
  • Vaccinate employees against threats they are exposed to, such as hepatitis B (HBV)
  • Establish and use sharps safe handling and disposal protocols, following CDC “One and Only Campaign”
Infection Control
  • Early detection of medical conditions that are hazardous and contagious during the client assessment;
  • Follow universal precautions for every client. As outlined by the CDC, treat all blood, bodily fluids, secretions, excretions (except sweat,) non-intact skin and mucous membranes as if they contain infectious agents;
  • Use appropriate personal protective equipment such as gloves and masks, gowns, eye protection depending on the exposure, and rigidly follow hand hygiene practices;
  • Vaccinate employees against influenza;
  • Soiled client care equipment – wear gloves if visibly contaminated and follow proper hand hygiene practices;
  • Laundry – handle to prevent the transfer of any microorganisms to others and the environment;
  • Client resuscitation – use a ventilation device to prevent contact with oral secretions;
  • Coughing and sneezing – instruct employees to cover their mouth, dispose of tissues in a no-touch container, wash hands, maintain a 3’ or greater separation, wear a mask if tolerated.

        Home healthcare workers face the potential for violence ranging from verbal and psychological intimidation to physical violence and assault. In addition to facing many of the same risks encountered in any healthcare setting, workers may find themselves alone, often at night, in high risk or high crime areas and in the presence of animals, guns and family members. Family members with a history of violence, under the influence of drugs or alcohol or diagnosed with a mental illness increase the danger to the home care worker. Unlike the hospital, the home care agency does not control the environment.

        Client care can also be affected where the fear of violence causes the home care worker to limit visit duration or to cancel appointments.

Prevention and Control:
  • Training and education about the risk of violence, identification and response to agitation, disruptive and aggressive behavior and conflict de-escalation techniques;
  • Patient, family member and home assessment;
  • Clear policies and procedures for handling threats;
  • Personal alarms, cell phones, escorts;
Liability risks.

        Home healthcare workers, and their employers, are uniquely exposed to potentially significant liability risks associated with working unsupervised in a client’s home. While in that environment, anything that happens to the patient or their property can potentially be viewed as under the care, custody and control of the HHC agency. Incidents can translate into claims of sufficient magnitude to put the organization at financial risk.

         Client Falls

         The most frequent type of situation resulting in claims involves client falls. Those that usually occur that result in claims are most often associated with client transfers, and can occur when providing professional medical services or when attending to activities of daily living.

  • To and from beds;
  • Transfer to/from toilet or bath tub;
  • Assisting the client with walking;
  • Falls from wheelchairs;
  • Falls when getting in and out of automobiles.

        Beyond physical and mental impairments or other client characteristics, HHC workers often have to contend with tight confines, trip and fall hazards, poor lighting, animals, family members, poor or deferred maintenance and other conditions that increase physical risk.

        One of every three older adults falls one or more times each year. Fall-related injuries are the leading cause of injury, death and disabilities in adults over 65, the most serious injury being hip fracture. Half of older adults hospitalized for hip fracture never regain their former level of function, and nationwide only 50% of older adults hospitalized for hip fracture are able to return home or live independently after the injury.

        The American Geriatric Society’s Guidelines for Prevention in Older Adults advises “providers across diverse settings need to screen individuals for risk using generic criteria at multiple points of access,” “adding “all people identified at risk should be offered a multi-factorial assessment and tailored interventions..

        Ethical Issues

        Home health care workers are often faced with disturbing ethical issues; among them, illegal activities going on in the home. HCW may be confronted with illegal drug dealing or consumption. Home Care staff are conflicted as to whether to report this to the police for fear of retaliation or, if unable to return to the home and the client, the client ‘s health may be endangered or compromised.

        Gender and Race Issues

        Sexual harassment has been reported by both sexes while on the job. Young female nurse’s report being particularly vulnerable be it by male patients or family members. Men also reported being harassed by clients.

        Racial issues, where staff of a particular race went into neighborhoods or a home of a different race, increased staff fears and perceptions of risk.

        Professional care services

        Some of the most expensive claims relate to situations where Home care services are not provided as provided in physician instructions and care plans. These types of claims are typically associated with:

  • Failing to notice a new infection;
  • Failing to perform contracted services;
  • Not identifying fundamental changes in the client’s condition.
        Theft and damage to client property

        Theft and damage to client property, including access to personal health and other confidential information can be a serious problem.

  • Criminal background checks on all employees needs to be mandatory. Be sure to understand the laws of your state and how they apply. In general, you should be able to deny employment to any prospective employee with a felony conviction or a felony or misdemeanor related to physical abuse or assault, theft or fraud.
  •  Develop specific policies on what employees are or are not allowed to do regarding client finances, purchases or anything related to personal records. Employees should not be allowed to use a caregiver or client credit card under any circumstances, and any other access or use of funds to purchase personal items for the client should be specified in the contract with the client or their caregiver.
  •  Another area to watch for is theft of telephone services. Consider blocking international calls.
  • Damage to furniture and potentially the HHC worker and client, can occur when handling cleaning chemicals. Avoid bleached based solvents. Candles cause fires. Avoid fires of any kind if at all possible. Turn down the water heater to medium heat.