Scope of Practice

Scope of practice defines the tasks that health care workers are legally allowed to perform. For example, there are some procedures that HHAs may not perform because they are considered to be outside of the scope of practice. In the U.S., there are variations that exist from state to state about what a HHA can do. It is important to be aware of the rules and regulations that pertain to the state in which the HHA works. According to the New York State Department of Health (2009), the following includes a list of tasks that HHAs may not perform:

Tasks that HHAs may NOT perform include:

• HHAs may not administer medications unless trained and allowed to do so by their state and agency. In certain situations and with special training a HHA may assist patients with self-administration of medications.
• HHAs may not insert or remove tubes from a patient’s body. Examples may include, but are not limited to insertion of catheters, fecal containment devices, nasogastric tubes, feeding tubes, and intravenous catheters. Insertion of a tube or object is considered an invasive procedure and may only be performed by licensed professionals.
• HHAs may not perform sterile procedures. This includes changing dressings on deep, open wounds which require sterile technique. HHAs may assist a licensed professional with completion of these tasks by gathering supplies, distracting a patient, or assisting with cleanup after the procedure once the sterile area has been covered.
• HHAs may not perform a task or duty that is outside of their scope of practice or that has not been assigned to them. When working as an HHA, there may be situations in which a patient or family asks the HHA to do something they are not trained or allowed to do. In these situations, the HHA should explain that they are not allowed to perform that particular task. They should then seek the assistance of their direct supervisor. It is always the right of the HHA to refuse to complete a task that is outside of their scope of practice.

Scope of Practice for PCAs:

In general, remember that PCAs may not perform any medically-related task. They may not administer or assist patients with medications under any circumstance. They may not provide assistance with dressing changes, apply medicated lotions to a patient’s skin, or take vital signs.

Chain of Command

Care plans, which are the prescribed treatments and services a patient will receive are developed from input from all members of the team. There may be many care plans for a patient who has many needs. For example, a physical therapist will develop a care plan for mobility needs after assessing the patient. The registered dietician will develop a care plan for nutritional guidelines for the patient to follow. The supervisor, who is often a registered nurse, will coordinate the care the patient will receive.

Home health aides and personal care aides work under the supervision of a Registered Nurse (RN). The supervisor will provide the HHA/PCA with a care plan to follow. It is important that the instructions written on the care plan are followed. This ensures that the patient receives the proper and safe health care they deserve. It also protects the HHA/PCA and the agency for which they work from liability. Liability means that the employee (the HHA/PCA) or the agency for which they work can be held legally responsible for harming a patient. For example, if the HHA/PCA did not follow what was instructed in the care plan and performed a task outside of their scope of practice, such as inserting a urinary catheter, and harm comes to the patient, the HHA/PCA and the employer (the agency) are legally liable

Care plans are updated regularly to ensure the patient’s needs are being met. They are also updated when there are changes in a patient’s condition. As the person on the healthcare team who spends the most time directly with the patient, the HHA/PCA will have first-hand knowledge of the patient’s condition. It is important that they immediately report any change in patient condition to their supervisor, and that these changes are documented. For example, an HHA/PCA may observe that the patient is weaker than a previous visit, which puts the patient at a greater risk for a fall. It is important that these observations are documented and reported to a supervisor. Other examples of changes that may be noticed include: a change in the patient’s behavior, unexplained bruises, skin breakdown, or an unsafe situation in the home, such as cluttered hallways, which may be a trip hazard. These would be important observations to document and inform a supervisor about.

While patients always have the right to refuse treatments or assistance, it is important that the HHA/PCA document these refusals and inform their supervisor. Under an HHA/PCA’s employment conditions and certification requirements, they may be legally liable to report changes in patient conditions and within patient environments. If an HHA/PCA is ever unsure of a situation or an observation, they should talk to their supervisor. It is important to follow the care plan and instructions from supervisors to protect oneself, the agency, and most importantly, the patient.