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PRIVATE DUTY
Policy Number:
Facility Name:
Manual Title:
Functional Area:
Effective/Revision Date:
Policy/Process Owner:
Approved By:
Review Date:
Attachments:
INV.HC.100
Inverness Village
Nursing Department Policy and Procedure Manual
Nursing
June 1, 2006
Debby Raskin, PHR, Director of Human Resources
Terry Thompkins, Executive Director
May 2007
Private Duty Sign in Sheet
Definition:
Private sitters/companions/attendants/licensed nurses (hereinafter referred to as “Private Duty Staff”)
are individuals hired directly by the resident/family or through an agency contracted by the
resident/family to provide care and services defined by the resident/family. Private Duty Staff are not
considered employees or volunteers of Inverness Village. All Private Duty Staff must be licensed or
certified by the State of Oklahoma.
Policy:
Routine care rendered by private duty nursing staff will conform to all Inverness Village policies and
procedures and will include attention to physical, emotional, social, and spiritual and life style
preferences in the provision of care to the resident. The resident’s overall care and wellbeing remain the
responsibility of Inverness Village.
Procedure:
1. All Private Duty Staff will provide the following required documentation to the Inverness Village
before beginning private duty care:
 Criminal background check on any staff who work at Inverness Village
 Verified copy of license or certification if applicable
 Up to date PPD or TB Surveillance form or Chest X-Ray
 List of training classes that the private duty staff attended
2. A list of private duty nursing agencies is maintained by social services. Agencies will provide the
following required documentation to Inverness Village:
 Evidence of the agency’s Liability Insurance in an amount not less than
$1,000,000/$3,000,000.
3. If the resident or responsible party seeks advice or assistance in hiring Private Duty Staff, social
services will provide a list of agencies. The resident or responsible party may utilize an agency of
their choosing; however, Social Services or Human Resources must be notified so that the
required documentation can be obtained.
4. The Private Duty Staff may not work at Inverness Village until the above listed items are received
by the Human Resources Office. In addition, the Nursing Office Coordinator/designee will
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ensure that an individual or agency is not listed on the OIG Exclusion List.
5. All Private Duty Staff must wear a name badge at all times. If name badges are not worn, Private
Duty staff may be asked to leave the facility.
6. Before reporting for duty for the first time, the Private Duty Caregiver will report to the Charge
Nurse or Manager on Duty. Human Resources will confirm that the required documentation is
received. If the individual/agency has not given prior notice to the facility that a private duty
employee was being sent to the facility, and the required documentation is not on file, then the
agency will be called and documentation faxed over. If it is after hours, the agency employee
must provide a copy of his/her background check and their license or certificate and PPD/Chest
X-ray to work at the facility. If those items are not available, the private duty staff will not be
allowed to provide care. The Director of Human Resources will contact the agency on the next
working business day to obtain the necessary documentation.
7. Upon arriving at the facility the first time, the private duty employee will be given the list of
Private Duty Staff Requirements and Responsibilities (see attached), and will sign the Agreement
for Private Duty Staff (attached).
8. The Private Duty Staff report to the assigned unit and must sign in and sign out on the Private
Duty Log form at the Nurses’ Station daily.
9. Private duty licensed nurses are not permitted to write in the resident’s record, but may read the
chart.
10. Private duty licensed nurses are not permitted to administer medications, tube feedings or
perform wound/pressure ulcer treatments or administer any other treatments to the resident.
These duties will be carried out by the Inverness Village licensed nursing staff.
11. Private duty nursing assistants are not permitted to read or document on the Nursing Assistant
documentation flow records. This documentation will be performed by the resident’s primary
Nursing Assistant/designee after receiving input from the private nursing assistant.
12. The charge nurse will ascertain the private duty caregiver’s credentials and give the private duty
caregiver a status report on the resident based on caregiver’s level of credential. The report will
include information regarding the resident’s plan of care, and specifics of the resident’s care
needs.
13. The charge nurse/nurse manager/shift supervisors are responsible for supervising the care of the
resident. The charge nurse will perform the following duties to ensure that care is being given to
the resident in the appropriate manner:
a. Observe the resident no less than every 2 hours
b. Meet with the private duty care provider at the beginning of the shift to review the resident’s
specific needs and direct the staff regarding care concerns that need to be monitored and
reported to the charge nurse.
c. Direct the private duty staff in the provision of care according to the care plan and the care
giver’s credentials, and direct the staff in specific tasks that are required such as
appointments, positioning, dietary needs, etc. as appropriate.
d. Observe the private duty caregiver as needed when providing care to ascertain that the
individual is competent to perform the duties required.
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e. Be a resource to the private duty caregiver for any questions or concerns that may
arise during the shift.
f. Obtain report from the private duty caregiver at the end of the shift.
g. Report any concerns regarding the private duty caregiver’s performance to the
resident or responsible party.
14. The Private Duty Nursing Assistant will be responsible for the following, as applicable, during
that tour of duty:
a. Bathing/dressing
b. Room tidiness/bed making
c. Toileting
d. Mobility as indicated
e. Turning and positioning
f. Meal assistance/Offering fluids/feeding
g. Patient social stimulation
h. Seeing to resident’s safety needs
i. Following standard precautions or special isolation precautions as directed by the charge
nurse.
j. Reporting care information to the primary Nursing Assistant so that he/she can complete
required documentation.
i. Meal percentage
ii. Amount of assistance with meals
iii. Resident’s acceptance or refusal of snacks
iv. Number and description of bowel movement(s)
v. If resident had a shower or tub bath
vi. Amount of assistance provided with ADL’s
vii. Care needs that were met such as oral care, ambulation, turning and positioning, etc.
k. Reporting any and all changes in condition to the charge nurse immediately.
15. Two person or mechanical lift transfers MUST be performed with the primary Inverness Village
Nursing Assistant.
16. To assist the staff with frequent resident observation, the resident’s room door is to remain open
except during personal care and/or at the resident’s request.
17. The Private Duty Staff will give a concise report to the charge nurse when reporting off duty, and
will also notify the Charge Nurse immediately of any change in condition.
18. All Private Duty Staff are required to identify themselves at the gate house and must give the
following information. Entrance to the campus will be denied if the information is not given.
a. Their name
b. The name of the agency they represent
c. The name of the resident with whom they have an appointment.
**Note** Former employees of Inverness Village may not provide Private Duty Services on the
Inverness Village campus for a period of six (6) months following their last day of work and it is
subject to the approval of the Director of Human Resources at his/her total discretion.
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PRIVATE DUTY REQUIREMENTS AND RESPONSIBILITIES
You will be responsible for the care of the patient during the time that you are here. There is also a
facility nursing assistant assigned to your resident. If you need help with the resident’s care, ask the
facility nursing assistant for help. You must have the assistance of the nursing assistant for 2 person
transfers and for any mechanical lift transfers. You also must ask the nursing assistant to assist you
the first time you shower or bathe your resident in the bather room.
Your duties include the following:
 Bathing/dressing
 Room tidiness/bed making
 Toileting
 Mobility as indicated
 Two person or mechanical lift transfers MUST be performed with the primary Inverness
Village Nursing Assistant.
 Turning and positioning
 Meal assistance/Offering fluids/feeding
 Resident social stimulation
 Seeing to the resident’s safety needs
 Checking out all supplies through the primary Nursing Assistant
 Following standard precautions or special isolation precautions as directed by the charge
nurse.
 Reporting care information to the primary Nursing Assistant for the purpose of completing
the Nursing Assistant documentation.
 Reporting any and all changes in condition to the charge nurse.
While you are here, the charge nurse is your supervisor. The charge nurse will tell you the care
needs of your resident and will observe you to be sure that the appropriate care is being given. You
are expected to follow the directions of the charge nurse, and to report any change in the resident’s
condition immediately.
The charge nurse will do the following to help you:
 Observe the resident no less than every 2 hours
 Meet with you at the beginning of the shift to review the resident’s specific needs and direct
you regarding special care needs of the resident.
 Observe you when providing care to be sure you are comfortable performing the tasks that
are assigned to you.
 Be a help to you for any questions or concerns that you may have during the shift.
 Meet with you at the end of the shift to get report on the resident’s status.
To assist the staff with frequent resident observation, the resident’s room door is to remain open
except during personal care and/or at the resident’s request.
At the end of the shift you will meet with the facility Nursing Assistant and report the resident’s care
so that the Nursing Assistant can complete the Nursing Assistant documentation. You will also give a
concise report to the charge nurse when reporting off duty.
Additionally, while you are assisting residents at Inverness Village you will be expected to follow
the following policies that all of our associates abide by:
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The private duty personnel will be free of infectious conditions such as influenza, colds,
skin rashes, etc., that can easily be transmitted to the resident.
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The use of tobacco is prohibited inside the buildings of Inverness Village. Smoking is
permitted only in designated areas.
The private duty personnel will keep the resident’s personal and medical information
confidential as required by state and federal laws.
Private duty personnel will not solicit employment with other residents or resident families.
Employees of Inverness Village will not be responsible for verification of hours worked by
the private duty personnel.
Private duty personnel will provide services for his/her employer only.
Private duty personnel will notify Inverness Village’s nurse’s station if they are unable to be
present or will be leaving early.
Private duty personnel will follow Emergency Procedures as directed by the Director of
Nursing or Designee.
Dress in an appropriate manner for the services being provided. Inverness Village policy
does not allow shorts or open toed shoes while caring for residents.
Meals can only be taken at Inverness Village by prior arrangement.
Parking is permitted in the lots designated for “Employee Parking.” Parking is not allowed
in areas designated for “Visitors” or “Handicapped.”
If violations of these guidelines occur, the details surrounding the violation will be put into writing
and a meeting with the Coordinator of Social Services, the Director of Nursing, the Administrator and
the Private Duty personnel will be held. The Private Duty personnel will sign the written report to
confirm the information was presented. A copy of the report will be sent to the Private Duty personnel
employer. Private Duty personnel will be provided space in which to add additional information. If
further steps are necessary to correct the situation, a meeting with the employer will be requested.
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Agreement for Private Duty Staff
The undersigned, a private sitter/companion/attendant/licensed nurse (the “Private Duty Staff”) in
consideration of being permitted to render services to __________________________ (the
“Resident”), a resident of Inverness Village being cared for at this facility hereby agrees with the
Facility as follows:
1. The Private Duty Staff shall be an employee of the Resident or the contracted agency and not an
employee of this facility.
2. The Private Duty Staff shall be required to follow all rules, regulations and practices of the facility
and will not exceed any Federal or State Practice Acts in rendering services to the Resident.
3. The Private Duty Staff will not interfere with care rendered by the Facility to the Resident.
4. The Private Duty Staff understands he/she will not be covered by any worker’s compensation,
professional or medical insurance by the Facility.
5. The Private Duty Staff will defend, indemnify and hold the Facility harmless from any claims
including attorney’s fees for acts omissions of the Private Duty Staff at the Facility.
6. In the event the Private Duty Staff disrupts or interferes with the operations of the Facility, or
Facility believes that the level of care provided by Private Duty Staff is inadequate or inappropriate,
it shall have the right to remove and prohibit the Private Duty Staff from the premises of the
Facility.
7. The Private Duty Staff has not been found guilty of abusing or mistreating the elderly in a court of
law or has not had a finding entered in to the State Board of Nursing/Nursing Assistant Registry
concerning abuse, neglect, mistreatment or misappropriation of property against the elderly, or
excluded from participating in federal or state health care programs.
8. The Private Duty Staff has received a copy of the Private Duty Staff Requirements and
Responsibilities.
Dated this ___________ day of _______________, ___________
________________________
Facility Representative
________________________
Private Duty Staff
_______________________
Witness
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Agreement for Resident/Representative
The undersigned, a resident (the “Resident”) of Inverness Village (the “Facility”), desiring to hire a
sitter/companion/attendant/licensed CNA, LPN, or RN nurse (collectively the “Private Duty Staff”)
for personal services while being cared for at the Facility hereby agrees with the Facility as follows:
The Private Duty Staff shall be an individual/agency acceptable to Facility. The Facility reserves the
right to reject any Private Duty Staff who previously been employed by The Facility. Resident agrees
to discuss the hiring of Private Duty Staff with the Director of Nursing or her designee. Resident
understands that if Private Duty Staff that does not comply with the rules of the Facility the Private
Duty Staff will be asked to leave the Facility and will not have the opportunity to provide services to
any Resident.
1. The Private Duty Staff shall be required to follow all rules, regulations and practices of the Facility
in rendering services to the Resident. Resident understands that in the event the Private Duty Staff
fails to comply with the rules and regulations of the Facility and/or disrupts or interferes with the
operations of the Facility, the Facility shall have the right to remove and prohibit the Private Duty
Staff from the premises.
2. The Private Duty Staff will not interfere with care rendered by the Facility.
3. Meals for Private Duty Staff can only be taken at Inverness Village by prior arrangement from the
resident/representative and will be paid by the resident/representative.
4. A written request must be provided to the Facility by the resident/representative for residents to
be taken by the Private Duty Staff outside the facility.
5. The Resident hereby releases and agrees to defend, indemnify and hold the Facility harmless from
any claims resulting from any action taken by the Private Duty Staff in caring for the Resident.
Dated this ____ day of _______________, _______
________________________
Facility Representative
________________________
Resident or Authorized Representative
________________________
Witness
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Resident Name: ________________________________
PRIVATE DUTY SIGN IN/OUT SHEET
DATE
NAME
CNA/GNA
/HHA
LPN/RN/
OTHER
AGENCY
TIME IN
TIME OUT
Revised 04/06
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