Training Module — New Hire 07: Scope of Practice

Policy Reference: NC-08 — Skilled Nursing Services | NC-09 — Home Health Aide Services

Learning Objectives

By the end of this module, you will be able to:

1. Define scope of practice for your role — whether HHA/companion or RN/LPN.
2. List specific tasks that are outside your scope and explain why.
3. Describe the correct response when a patient or family requests a task outside your scope.
4. Explain the supervisory visit process and what to expect during one.
5. Identify the elements of your assignment sheet or skilled nursing care plan and how to use it.
6. Explain how non-skilled and skilled nursing services work together at Noble Care.

Key Points

What You Are Authorized to Do
Your authorized tasks are documented on your Client Assignment Sheet. You may only perform tasks that are explicitly listed. When in doubt — don't do it. Ask first.

Authorized Non-Skilled Tasks Include:

• Personal care: bathing/showering (with proper technique), grooming, oral hygiene, dressing, toileting, incontinence care
• Transfers and ambulation (per care plan — note weight-bearing status and assistive device requirements)
• Meal preparation per patient preferences and dietary restrictions
• Light housekeeping (cleaning areas used by the patient, laundry)
• Companion activities: conversation, reading, games, accompanying to appointments
• Vital signs observation (if authorized — noting, NOT interpreting)
• Medication reminders (verbal reminder that it is time to take medication — patient self-administers)

What You Are NEVER Authorized to Do (Regardless of Who Asks)

When a Patient or Family Asks You to Do Something Outside Your Scope

1. Do not do it.
2. Do not apologize excessively or make the patient feel bad.
3. Say calmly: "That's not something I'm authorized to do, but I want to make sure you get the support you need. Let me call the office and we can get the right person to help."
4. Call your supervisor and document the request in your visit note.

Your Assignment Sheet
Every shift, you should have a current assignment sheet that lists:

• Patient name, address, emergency contacts
• Authorized tasks with specific instructions
• Dietary restrictions and preferences
• Fall risk and transfer instructions
• Supervisor contact information

If your assignment sheet is outdated, unclear, or does not match what the family is requesting, call the office before starting care.

Professional Boundaries
Maintaining professional boundaries is essential to patient safety and your own protection. Noble Care strictly prohibits:

• Personal relationships with patients or their family members (social outings, exchanging personal phone numbers for non-work purposes)
• Romantic or sexual relationships with any patient — this is never acceptable regardless of circumstances
• Business relationships with patients (buying from, selling to, or investing with patients or their families)

If a patient or family member initiates a boundary-crossing interaction, redirect professionally and notify your supervisor. Boundary violations are grounds for disciplinary action up to and including termination.

Supervisory Visits
Your supervisor will conduct periodic in-home supervisory visits to observe your care, review your documentation, and provide feedback. These are not evaluations to fear — they are a required support mechanism.

Supervision Frequencies:

• HHAs under skilled care plan: In-home supervisory visit every 14 days
• HHAs under non-skilled care plan: Monthly telephone or electronic contact with the patient, plus an in-home supervisory visit every 60 days
• New employees (all roles): More frequent supervisory visits during the initial orientation period

PART B — Skilled Nursing Scope of Practice (RN/LPN)

This section applies to Registered Nurses and Licensed Practical Nurses providing private-pay skilled nursing services at Noble Care.

Role Overview
Noble Care's skilled nursing staff provide clinical services to private-pay patients in their homes. The Administrator (RN) provides clinical oversight of all skilled nursing operations. PRN (as-needed) RNs and LPNs deliver direct patient care under the Administrator's supervision.

Authorized Skilled Nursing Tasks (RN)

LPN Scope — Delegated Tasks
LPNs work under the direction of the Administrator (RN) and may perform:

• Medication administration (oral, topical, IM injection)
• Wound care and dressing changes
• Vital signs and clinical observations
• Patient education reinforcement
• Documentation of skilled visits

LPNs may NOT independently:

• Perform initial patient assessments (RN responsibility)
• Develop or modify the skilled care plan (RN responsibility)
• Administer IV push medications (RN only in Ohio)
• Perform PICC line insertion (RN only)
• Make clinical judgments about plan of care changes without RN consultation

Skilled Nursing Documentation Requirements
Every skilled visit must include:

1. Reason for visit — clinical purpose (wound care, med management, assessment, etc.)
2. Subjective findings — patient-reported symptoms, complaints, changes
3. Objective findings — vital signs, wound measurements, physical assessment findings
4. Assessment — clinical interpretation of findings, progress toward goals
5. Plan — interventions performed, changes to care plan, follow-up needed, physician notifications
6. Patient/caregiver education — topics taught, understanding verified
7. Time in and time out — actual visit duration for billing

Documentation must be completed within 24 hours of the visit. Late or incomplete documentation delays billing and creates compliance risk.

Skilled Nursing Care Plan
Unlike non-skilled assignment sheets, skilled nursing operates from a Skilled Care Plan that includes:

• Medical diagnosis and relevant history
• Physician orders (if applicable — not required for all private-pay services)
• Measurable clinical goals with target dates
• Specific skilled interventions and frequency
• Medication list and administration schedule
• Parameters for physician notification (e.g., "Notify MD if BP > 180/100")
• Patient/caregiver education goals
• Anticipated discharge criteria

The RN reviews and updates the skilled care plan at least every 60 days and whenever a significant change in patient condition occurs.

How Skilled and Non-Skilled Services Work Together
Many Noble Care patients receive BOTH skilled nursing and non-skilled services. Example:

• A post-surgical patient receives 3 RN visits per week for wound care and medication management
• The same patient also receives 20 hours per week of HHA personal care (bathing, meals, light housekeeping)
• The RN develops the care plan that guides both the skilled visits and the HHA assignment sheet
• The HHA reports observations to the RN (e.g., wound drainage on bed linens, patient complaints of pain)

Communication between skilled and non-skilled staff is critical. If an HHA observes a clinical change, they report to the supervising RN. If an RN identifies a need for additional non-skilled support, they coordinate with the office.

Prohibited — All Staff
Regardless of licensure, NO Noble Care staff member may:

• Provide services outside their individual scope of practice or licensure
• Accept gifts valued over $25 from patients or families
• Maintain personal financial relationships with patients
• Perform tasks not authorized in the care plan or assignment sheet without supervisor approval
• Photograph patients without written consent (NC-F-08A)

Real-World Scenarios

Scenario 1 — HHA Scope

After 6 months on the job, Priya is one of the most trusted caregivers for the Wilson family. One day, Mrs. Wilson's daughter calls and says, "I know you're not technically supposed to do this, but Mom's regular nurse is out sick. Can you just draw up her insulin? You've seen it done a thousand times and you know what dose she takes."

Why Priya must refuse, even with the best intentions:

• Drawing up and administering insulin is a medical act requiring a nursing license under Ohio law.
• If Priya gives the wrong dose — or even the right dose at the wrong time — she could cause serious harm.
• Noble Care's liability would be severe, and Priya could face personal legal consequences.
• Priya is not covered by malpractice insurance for tasks outside her scope.

What Priya should say:
"I understand how stressful this is, and I really want to help. But giving insulin is something I'm not trained or licensed to do — if something went wrong, it could seriously hurt your mom. Let me call the office right now. Noble Care has skilled nurses who can come out and administer her insulin — we may be able to arrange coverage today."

Scenario 2 — Skilled Nursing Scope

Rachel is a PRN RN covering a wound care visit for a post-surgical patient, Mr. Torres. During the visit, Mr. Torres mentions he's been having chest pain since yesterday but "didn't want to bother anyone." His vital signs show BP 168/102 and pulse 98. Rachel also notices his living room is in disarray and his refrigerator is nearly empty.

What Rachel should do:

1. Address the clinical emergency first: Assess chest pain (onset, duration, character, severity). With elevated BP and tachycardia, this may require 911. Follow physician notification parameters in the care plan.
2. Document thoroughly: Record the chest pain assessment, vital signs, interventions, and physician communication in the visit note.
3. Coordinate non-skilled support: Call the office to report that Mr. Torres may need HHA services for meal preparation and light housekeeping — this is not Rachel's role during a skilled visit, but she identifies the need and refers it.
4. Do NOT try to clean the house or prepare meals during the skilled visit — that's scope creep in the other direction. Skilled visit time is billed at the skilled rate and must be spent on skilled interventions.

Why this matters: Skilled nurses must stay within their visit purpose while still recognizing and escalating non-clinical needs. The strength of Noble Care's model is that one agency provides both — Rachel identifies the need, and the office coordinates the HHA support.