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Staffing Issues in Home Health

Employment of home health aides is expected to grow by 60 percent between 2010 and 2020.

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Be it for finding help for an elderly family member or transitioning to a career in home health, increasing numbers of nurses are intersecting with the ever-growing elder care industry.

And, though thriving, it's an industry with a lot of recent attention for objectionable practices.

A recent study by Northwestern Medicine in Evanston, IL, and recently published by the American Geriatrics Society revealed many agencies recruit random strangers off Craigslist and place them in the homes of vulnerable elderly people with dementia, don't perform national criminal background checks or drug testing, lie about testing the qualifications of caregivers and don't require any experience or provide real training.

"People have a false sense of security when they hire a caregiver from an agency," said lead study author Lee Lindquist, MD, associate professor of medicine at Northwestern University Feinberg School of Medicine and a physician at Northwestern Memorial Hospital. "There are good agencies out there, but there are plenty of bad ones and consumers need to be aware that they may not be getting the safe, qualified caregiver they expect. It's dangerous for the elderly patient who may be cognitively impaired."

Home Health vs. Home Care

One important distinction in any discussion of care in a home setting is the difference between agencies providing home care and home health. Home health is doctor-prescribed and agency employees are considered skilled with special training. Home health care nurses can administer medication.

According to the Bureau of Labor Statistics, employment of home health aides is expected to grow by 60 percent from 2010 to 2020.

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By contrast, home care involves simple assistance with activities of daily living. These workers can remind a patient to take medication, but not administer the pills. Marie Fredette, executive director at the Arizona Association for Home Care said questionable home care and home health agencies are frequently confused and the consequences can be deadly.

"Home care agencies are not required to be licensed and don't even need to have to have business license," she noted. "There's no oversight and we hear of some giving medication when they're not permitted.

When working with medical home care companies, it's essential to check for the state's department of health website for the agency's Medicare certification status and any possible citations brought against the agency.

Linquist and other researchers surveyed 180 agencies nationwide. Of those, only one-third tested for caregiver competency and more than 58 percent relied on self-reporting to assess caregiver skills.  

Several agencies surveyed in the study actually made up names of screening tests they claimed to give their job applicants.

"We had agencies say they used a 'National Scantron Test for Inappropriate Behavior' and an 'Assessment of Christian Morality Test'," Lindquist said. "To our knowledge, these tests don't exist. If you're not a smart consumer, you won't recognize which agencies are being deceitful."

Insufficient Background Checks

One of the study's most disturbing findings was the fact that only 55 percent of agencies performed a federal background check and only one-third tested for drugs.

"A number of agencies don't do a federal background check or look at other states besides their own," Lindquist said. "Someone could move from Wisconsin to Illinois and could have been convicted of abusing an elder adult or theft or rape and the agency would never know." 

The drug test is another murky area as well. Fredette said that, in Arizona, TB testing in required by drug testing is at the agency's discretion.

In neighboring California, Mission Healthcare executes an 11-panel drug screen, while the industry standard is a 6-panel test. Marijuana, cocaine, opiates, methamphetamine, amphetamine, PCP, benzodiazepines (Valium, Xanex, Ativan), barbiturates, oxycotin and ecstasy are all included in the screening.

"We take it very seriously because these individuals are going into homes with a lot of medications," said Kerry Pawl, DPT, director. "If someone tests positive and is looking for the big name drugs, we'll know that ahead of time."

Competency Requirements

In addition to the lack of screening, many agencies don't require any kind of basic competencies for caregivers.

According to the study, only one-third test for caregiver skill competency. The study uncovered common method of assessing skill competencies was "client feedback," which was explained as expecting the senior or family member to alert the agency that their caregiver was doing a skill incorrectly.  

That's not the case with AAHC's members.

"Per Arizona requirements, our home health aide members have 12 hours of education yearly in infection control, HIPPA, patient rights, reading and recording temperatures, pulse and respiration, nutrition, transfer techniques, and more," she said.

Questionable Supervision

Supervisor support is another area that many agencies fall between the cracks, said Linquist. Ideally, agencies should send the supervisor on a home check frequently initially and then at least monthly. But this only happens half the time.

"Amazingly, some agencies considered supervision to be asking the caregiver how things were going over the phone or when the employee stopped in to get their paycheck," Lindquist said.  

At Mission Healthcare, Pawl said he'd heard enough horror stories to establish a monthly unannounced supervisor visit and client call within a week of admission to check to the caregiver's prowess.

Insider Tips

Those in the know offer a few tips to ensure the agency you're associating with-or entrusting to a care of a family member-is trustworthy.

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In addition to checking the state health department's website, Fredette advised looking into professional association alliances for the agency.

Additionally, though it's not a requirement for Medicare home health agencies, she said it's noteworthy to learn if a social worker and physical therapist are on staff.

"In Arizona, it's not required to have these professionals but they do understand the psychosocial issues in home health," she added.

For Pawl, in addition to the drug testing and background checks, it's important to go in knowing the agency's level of customer service.

"I'd ask about minimums and use caution when there's a 4-hour care minimum," he advised. "If someone only needs 45 minutes of care and the agency goes to that level of customer service to accommodate, you're in good hands."

Robin Hocevar is senior regional editor at ADVANCE.


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The home care industry was once a highly respected profession with self-imposed standards that have eroded throughout the years due to the greed of those operating these companies. At one time it was generally considered a requirement that a home health nurse would have 1-2 years of documented hospital experience and the industry would not hire without it. Because there are NO LEGAL STANDARDS by which these companies must operate these appalling practices continue. They will argue that they do follow standards but this is not the case due to the fact that home care providers can be viewed as doing a task that a family member can do. This is how they rationalize what they do. The problem is actually rampant throughout the industry, from the largest to the smallest of companies. Management often turns a blind eye due to pressure from those running the company or even because they may receive a cut of the financial gain. The following are examples of what may be encountered:

Unlicensed staff either from the US or foreign countries.

Shifts not filled but billed for, forms will be filled out by unknown persons, names of possibly legitimately licensed persons will be used.

Untrained staff may arrive requesting information on care of your family member.

Untrained staff may arrive and make dire mistakes due to attempting to do tasks with no knowledge of what they are doing.

You may be told the agency is either looking for or has found someone who can pass a certification for a specific skill. The fact is there may be NO ACTUAL CERTIFICATION. ASK FOR A COPY!

Fed Up,  RNDecember 15, 2012



The examples you site regarding lack of training and lack of background checks only scratches the surface of a huge problem,which is getting worse all the time.Even in a state which requires bg checks and skill "certification"-(which consists of bed making,assisting with the most simple ADLs like bathing,meals,toileting), most Home Health agencies hire immigrants who cannot even speak the language of their patients (unless they too are foreigners).My mother was at the mercy of these type people both at an ALF and when she finally had to wind up in Hospice at my home 3 yrs ago. It was so bad, I had to quit my own job,(retiring early) because she was receiving such poor care in the few hours I had to be at work.She was very frail (90lbs) and needed careful handling, but had bruises with hand prints from where they "helped" her out of bed by lifting her under the arms.Our state has such strict guidelines for reporting & proving abuse/neglect by caregivers that I had nowhere to turn. I was so overwhelmed by guilt that I couldn't prevent her last months being so awful.Me-a nurse 30 yrs, couldn't prevent it. Think how helpless the average adult child trying to care for a parent must feel.Maybe ignorance of how things should be may be a blessing in disguise for them.But the damage it is doing to the perception of the nursing profession will never be undone.I even tried teaching as a solution to the ignorance of these "caregivers",but quit in disgust because of the lack of compassion, lack of interest in learning even the most basic skills, and total lack of respect for educators that I encountered in these young adult "students". I am so so disappointed that many nursing professionals haven't been able to convey to the young nurses who show promise clinically of the importance of the first premise of nursing is compassion. Finally, I am afraid when I am older and might not be in such good health, that I will be encountering some of these same health care givers. The thought terrifies me.

Rebecca ,  RN,  retiredDecember 12, 2012
FT.Lauderdale, FL



Currently I assist with the care of a 93yr old as a volunteer. I have had to let four HHA go because of sleeping, making unauthorized telephone calls, poor hygiene, inability to read brought back ammonia when she was told to buy bleach, using computer even though I was there for at least an hour. Now there are two wonderful and trust worthy women that really do a great job. I am notified and available, most of the time within the hour. There has to be some oversight from family or concerned others. Especially since we are living longer and in many cases healthier.

Patricia Sumner,  RNDecember 12, 2012
RETIRED, NY



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