By Ericka Waidley, MSN, RN
December 2, 1999

Q: I have a BSN degree and a public health certificate that qualify me to work as a home health nurse. Why can’t I visit patients in their homes without being hired through a home health service or agency? Are there any laws or regulations that prevent me from working independently?

A: Although there are no laws that prevent you from practicing within your capabilities as a nurse, there are several reasons why doing so as an independent practitioner is neither realistic nor legal.

Basically, all of the regulatory agencies that establish guidelines and standards for practice in California now have specific areas dedicated to home health services. The California Department of Health Services (DHS) has regulatory guidelines that mandate the licensing requirements for home health services and for the provision of nursing services outside an acute care setting. To provide nursing care to a patient at home, you have to be licensed as a home health provider and be subject to the regulatory guidelines. Also, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has standards that include ambulatory care and home health services, and the Health Care Financing Administration mandates the reimbursement of the provision of these services.

Although it’s frustrating that it’s not as easy to provide quality care across the continuum of care as it was years ago, these rules and regulations are meant to protect both the patient and the practitioner. If you want to provide nursing care at a patient’s home, I suggest that you do so as an employee of a certified home health agency, which is required to meet the rules set forth by these regulatory agencies.

Q: I work in a recovery room at a 350-bed hospital. Our shifts are variable because of patient volume and the fact that we are a level 1 trauma center. After 11 p.m., we have one nurse on call until 7 a.m. I am concerned about the safety of having only one nurse in the recovery room when the variety of potential patients may require more hands and help than one nurse can provide. Are there any legal standards or policies that I may bring to the attention of my clinical manager?

A: Adequate staffing is a challenge. There are no stringent laws that mandate staffing ratios in the operating or recovery room. The guidelines set forth by our regulatory agencies (the JCAHO and the DHS) require that hospitals establish policies to assure safe and appropriate staffing for the delivery of patient care.

It is not unusual for a hospital to have a nurse on call for the night shift in a recovery room. Usually there is a surgical team on call and in some cases a back-up surgical team that may include the recovery room nurse. It is assumed, and may even be written into policy, that when more than one nurse is needed, the operating room nurse can accompany the surgical patient into the recovery room and cover the patient until another nurse is called in or until the patient is transferred. In some hospitals, the ICU can also act as a
backup to the recovery room, although this may not be practical in a busy trauma center. Another option is always the night supervisor, who should be ACLS certified and able to function in the recovery room when needed.

You should discuss concerns about patient safety further with your manager. You also should know what the back-up plans are for times when you get busy and whom you should call when additional resources are needed.