The Issue in Focus

Home care is a rapidly growing industry, and the core element of the services it provides is its staff. The number of people who work for home care agencies more than doubled from 700,000 in 2005 to 1.4 million in 2015, and another 800,000 individuals were estimated to work directly for consumers through publicly funded programs.

Home care is projected to create more than 600,000 additional jobs over the next decade, more than any other occupation in the U.S. economy. (PHI) Two key aspects of home care make staff-related risks unique in this setting: the fact that staff members usually work alone and the organization's general lack of control over the work environment.

Risks involving home care staff may affect staff members themselves, clients, family members, visitors, others who live in the building, and the home care organization. For example, health and safety risks, ranging from illness and injury to risks in the social environment and community (e.g., transgression of professional boundaries), abound in home care. Additionally, some improper employment practices, such as insufficient background checks, can pose risks to clients and family members, while others, such as discrimination or failure to address sexual harassment by a client, can pose risks to the staff member. All pose risks for the home care organization—in the form of tort liability, insurance claims, and sanctions for noncompliance with applicable laws or regulations. Additionally, organizations may face issues such as lost work time, high staff turnover, low morale, and bad publicity. Insurance claims may fall under professional liability, general liability, employment practices liability, executive protection or fiduciary liability, workers' compensation, short- or long-term disability, or automobile liability, to name a few.

This guidance article discusses home care risks involving staff, including employment issues; injuries, illnesses, and workers' compensation; and risks in the social environment and community. Home care staff face many other risks common to healthcare personnel (e.g., latex sensitivity), but this guidance article focuses on those that are of special concern or pose unique considerations in home care.

General resources for reducing risks involving home care staff include hazard review of home care occupational hazards from the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health (NIOSH), which provides recommendations for both home care organizations and staff.

Also see Occupational Safety Fact Sheets for Home Care Staff and Checklist for Home Care Staff Safety for other tools reproduced from NIOSH. For a broader discussion of home care risk management, see Home Care: An Overview.

Worker Safety

The largely uncontrolled environment of home care, along with other factors, puts personnel at risk of injuries and illnesses. This discussion reviews some of the most prominent risks of injury or illness to home care personnel, but it is not exhaustive.

In the home healthcare services industry, 104.0 cases of injury or illness involving days away from work (with or without job restriction or transfer) occurred per 10,000 workers in 2015 (U.S. BLS "Incidence Rates"). See Figure. Most Common Causes of Occupational Injury or Illness in the Home Healthcare Services Industry, 2015 for a breakdown of causative events frequently implicated in home care worker injuries and illnesses involving days away from work. Thirteen home healthcare workers died from occupational injuries in 2014 (U.S. BLS "Fatal Occupational Injuries").

Workers' Compensation

Because of the risk for injuries that home care workers face, workers' compensation claims are a key risk management concern. An analysis of Washington State workers' compensation claims for home health workers (including both professional and paraprofessional workers) identified common injury types. From 2003 through 2007, the most common site of injury was the back or spine (8.0% of accepted claims), followed by fingers (2.0%) and legs (1.8%). The most common accident type was nontraumatic soft-tissue musculoskeletal injuries of the neck, back, or upper extremities (52%), followed by falls from the same level (13%). Only 5.1% of compensable claims were for vehicle injuries, but the rate was higher than in all other industries (2.0%). In total, the accident types that were costliest to the program (in terms of medical treatment) were nontraumatic soft-tissue musculoskeletal injuries of the neck, back, or upper extremities; falls from the same level; vehicle accidents; and workers being struck by or against something. (Howard and Adams)

Resident Safety

Risks related to home care staff can affect clients in both direct and indirect ways. For example, issues such as inadequate criminal background checks, staff members exceeding their scope of practice, or inappropriate use of photography or social media can pose a variety of risks to clients and their family members.

Indirect risks pose concerns as well. For example, clients may experience poor continuity of care and face greater risk for errors if staff turnover is high, staff members may provide poorer care if stressed, and clients may be injured if staff members do not have necessary devices or use improper body mechanics when transferring the client.

Regulations and Standards

Home health agencies must comply with Medicare's payment regulations and Conditions of Participation to be reimbursed by Medicare. The Centers for Medicare and Medicaid Services' guidance for surveyors addresses staff-related issues, including personnel qualifications, personnel policies, personnel under hourly or per-visit contracts, duties and supervision of registered nurses (RNs) and licensed practical nurses (LPNs), and therapy and social services. It also addresses training, competency evaluation, assignment, duties, and supervision for home health aides (CMS).

Additionally, home care organizations must comply with a host of other laws, regulations, and standards—at local, state, and national levels—that address staff-related issues such as the following:

• Scope of practice and delegation, assignment, and supervision
• Background checks
• Credentialing (especially in regard to telehealth) and peer review
• Independent contractor versus employee status
• Minimum wage and overtime pay
• Discrimination, including sexual harassment
• Labor relations and collective bargaining
• Other matters involving hiring, firing, and employment
• Occupational safety and health
• Workers' compensation
• Driver licensing, insurance, and traffic laws and regulations

Some of these topics are discussed further in this guidance article. Information on others can be found elsewhere in CCRM.

Action Plan

Manage Risks in Hiring, Firing, and Retention

Action Recommendation: Manage risks in hiring, firing, and retention.

Because staff spend most of their day working alone in clients' homes, it is especially important that home care organizations' policies on hiring, discipline, termination, and other human resources issues be well designed and enforced uniformly. Policies must also conform to applicable federal, state, and local laws and other requirements. For more information, see Hiring and Firing.

Background Checks

Thorough background checks are vital. In 2006, a home care aide gave an 85-year-old client a fatal overdose of morphine and methadone; she then "ransacked" the client's home, according to reports. The aide, who was on drugs at the time of the incident, said that the overdose was accidental. She had a prior criminal record; she had been arrested several times and convicted for drug smuggling. The agency originally screened her only for crimes committed in the county where it was located. (Shishkin)

Home care organizations must take care to meet state requirements for obtaining criminal background information and requirements to report professional misconduct or other actions to licensing boards. The organization should check whether candidates and current employees have been excluded from federal healthcare programs by using the federal database, if applicable.

Driving records should also be checked for all applicable staff. Home care organizations may also consider testing employees for use of illegal drugs. For more information, see Criminal Background Checks and Employee Drug Testing.

Home care organizations may also face risks if they rely on staffing agencies to conduct background checks and verify clinical competence. In such situations, the home care organization should ask the staffing agencies it works with about their procedures for such checks and should request proof of background checks and verification of clinical competence for each staff member provided. It may also wish to work only with certified staffing agencies. (Rozovsky) For more information, see Employing Temporary and Agency Staff.

Organizations must also ensure that their use of criminal background information does not violate Title VII of the Civil Rights Act of 1964. In 2012, in an effort to address employment discrimination based on race and national origin, the U.S. Equal Employment Opportunity Commission (EEOC) revised its enforcement guidance on the use of information on arrests and criminal convictions during hiring (see Additional Resources). Because state law may conflict with EEOC's enforcement guidance, legal counsel should review the organization's background check process to ensure that it satisfies both state and EEOC requirements (Rozovsky). The licensure, qualifications, and experience of licensed professionals should also be verified.

Scope of Practice

Home care organizations must be familiar with all applicable laws addressing the scope of practice for all types of staff that they employ and ensure that staff do not exceed their scope of practice. Concern exists that some home care aides perform tasks that far exceed their scope of practice, as described in a 2014 Star Tribune (Minneapolis) article. Although personal care aides in Minnesota were required to pass an initial qualification test and were required by state law to be supervised by a licensed professional, training was often inadequate and many aides were thrust into situations that they believed forced them to exceed their scope of practice, the article reported. Many assistants interviewed by the author reported receiving only one hour of training before being sent to care for clients, then finding themselves in situations in which residents and patients required care that was much more technical than their skills allowed, or clients were even facing immediately life-threatening conditions. Personal assistants reported "routinely" performing such tasks as sterilizing wounds, administering prescription medications, and injecting medications. Similarly, although oversight of assistants by a nurse or other licensed individual was required, the author stated that nurses were often responsible for hundreds of personal care aides, residents, and patients, making their check-ins "cursory" at best. (Serres)

To address concerns about scope of practice, staffing should be carefully planned to meet clients' needs. Protocols and training can address what staff should do if a client's condition progresses to the point that he or she needs services beyond what they personally or the home care organization as a whole can provide.

Retention

High turnover, especially among aides, is a challenge in many home care organizations. High turnover rates can result in loss of trained, skilled staff and pose risks to continuity of care. Agencies with high turnover rates may also spend a lot of time and resources on recruiting, hiring, and training new staff.

One home care aide agency has described how a peer mentor program it developed for home health aides improved aide retention. Aides who have been with the agency for more than a year may be nominated to become a mentor. Nominees are interviewed; successful candidates undergo two days of training on topics such as peer mentoring and communication, cultural diversity, psychiatric and mental health disorders, palliative care, telehealth, and care of private-pay clients; they also undergo annual in-service training. All newly hired aides, aides who need special assistance, and other aides who need extra help (e.g., those who have undergone disciplinary action) receive a mentor. Mentors meet their mentees face-to-face and then call them regularly. Additionally, mentees are encouraged to contact their mentors on their own. Mentors keep journals of these conversations; they also call aides who have quit and report the aides' reasons for quitting to the performance improvement committee. Additionally, mentors are often assigned to more challenging clients. In return, they receive a promotion, a pay increase, and a cell phone stipend.

The agency started the program in May 2007, and as of 2010, the retention rate among mentors was 87%. The overall aide retention rate increased from 49% in 2008 to 57% in 2009. According to agency leaders, mentors are seen as well-trained, experienced aides; some nurses have begun requesting mentors to help care for specific clients. (Kreiser et al.)

Comply with Wage and Overtime Laws

Action Recommendation: Comply with laws addressing wages, overtime, and worker classification.

Organizations that offer home care services must ensure that home care workers are paid in accordance with laws addressing wages and overtime, notably the Fair Labor Standards Act (FLSA). In 2013, the U.S. Department of Labor (DOL) issued a final rule that extended FLSA's minimum-wage and overtime protections to most of the nation's workers who provide home care assistance to older adults and people with illnesses, injuries, or disabilities. Although home care provider associations sued, challenging the rule, a U.S. Court of Appeals ultimately affirmed the rule's validity. The association asked the U.S. Supreme Court to review the decision, but the high court declined to do so. (U.S. DOL "U.S. Court of Appeals") DOL offers resources and technical assistance to help home care agencies comply with the rule. DOL also offers guidance for clients or members of the client's household who manage home care services, who must pay minimum wage if they hire the worker directly or could be responsible for ensuring that the worker receives minimum wage if the services are arranged through an agency or a self-directed Medicaid program (U.S. DOL "Paying Minimum Wage").

However, the question of overtime is itself in flux. In May 2016, DOL finalized a rule requiring overtime pay (for working more than 40 hours in a week) for executive, administrative, or professional employees making up to $913 per week, or $47,476 per year. The previous threshold was $455 per week, or $23,660 per year. The rule would also automatically update the threshold every three years. However, the ultimate fate of the rule is currently undetermined. Two lawsuits challenged it, one brought by the attorneys general of 21 states and another brought by the U.S. Chamber of Commerce and more than 50 other business groups. In November 2016, the U.S. District Court of Eastern District of Texas issued a preliminary injunction to prevent the overtime rule from taking effect as planned on December 1, 2016. The order is a preliminary injunction only; as of this writing, DOL's authority to create the final rule and the rule's validity have yet to be determined. (Nevada v. U.S. Dep't of Labor)

Organizations must also take care not to misclassify workers for the purposes of FLSA. Observing an increase in misclassification of employees as independent contractors, DOL issued an administrator's interpretation addressing the issue. Noting that "most workers are employees under the FLSA's broad definitions," the interpretation outlined six factors to consider when determining whether a worker is economically dependent on the employer—and therefore an employee—or in business for him or herself—and therefore an independent contractor (U.S. DOL "Application"):

• Is the work an integral part of the employer's business?
• Does the worker's managerial skill affect the worker's opportunity for profit or loss?
• How does the worker's relative investment compare to the employer's investment?
• Does the work performed require special skill and initiative?
• Is the relationship between the worker and the employer permanent or indefinite?
• What is the nature and degree of the employer's control?

Home care workers have successfully sued based on alleged misclassification. For example, applying the factors listed above, the U.S. District Court for the Northern District of Florida found that a nursing assistant was an employee of a home care registry, rather than an independent contractor, and that she was therefore entitled to any overtime earned. Although she could refuse assignments and was not required to work a minimum number of days or hours, the court found that the registry exercised a great deal of control over the nursing assistant and that the nursing assistant had little to no independent opportunity for profit and loss, had worked for the registry for many years, and provided services that were integral to the registry's business. (Hughes v. Family Life Care) DOL offers resources on misclassification of employees as independent contractors.

Prevent Discrimination and Harassment

Action Recommendation: Enact policies and procedures to prevent and, if necessary, respond to discrimination and harassment.

Home care organizations must not discriminate against staff on the basis of factors protected by federal law (e.g., race, religion, color, sex, national origin, disability, age, pregnancy) or state or local law. Organizations must also stay abreast of—and comply with—developments regarding the application of sex discrimination laws and regulations to people of sexual and gender minorities.

Client preference does not excuse discrimination. In one lawsuit, a company that provided nonmedical home care through hundreds of franchises worldwide agreed to pay $150,000 to settle a lawsuit alleging race-based discrimination against employees. Over at least a few years, two franchised offices allegedly coded clients who preferred Caucasian caregivers by using "circle dots" and assigned caregivers based on these preferences. When a voluntary settlement could not be reached, EEOC filed suit, alleging violation of Title VII of the Civil Rights Act of 1964, in a U.S. district court. The company was also subject to monitoring by EEOC and was required to institute a policy forbidding race-based work assignments, annually train human resources personnel and recruiters, and post notices regarding the company's commitment to maintaining a discrimination-free workplace. (U.S. EEOC "Home Instead") For more information on discrimination, see Hiring and Firing.

Home care organizations must not engage in unlawful discrimination in regard to staff assignments based on sex. The Superior Court of New Jersey, Appellate Division, upheld a jury's finding that a home health agency's practice of barring male aides from caring for female clients was unlawful sex discrimination. A male home health aide brought the suit against his former employer, which allowed male and female aides to care for male clients but assigned only female aides to care for female clients. The court opined that an individual's privacy rights may justify sex-based job assignments in certain situations, such as those in which particular body parts are exposed or the individual is performing bodily functions. However, it found that the agency failed to show that it had a factual basis for believing that intrusion on these privacy interests was an essential part of the aide's job and that any alternative to a sex-based policy would have undermined its mission. For example, it did not ask clients about their privacy-based preferences before assigning staff. (Spragg v. Shore Care)

Home care organizations must also address situations in which clients or family members engage in discriminatory or harassing behavior toward staff. The following case involving sexual harassment, which is a form of discrimination on the basis of sex, provides one example. However, home care organizations must address discrimination on the basis of other factors protected by law as well.

EEOC sued a home health provider in a U.S. district court for failing to address a client's sexual harassment of multiple employees, which included groping the employees while they slept in their private quarters. The employees complained to several company officials, but the harassment continued. Two employees quit their jobs two months after being assigned to the client. EEOC filed suit after trying to reach a prelitigation settlement; it sought a permanent injunction to prevent the company from engaging in employment discrimination, plus back pay, compensatory damages, and punitive damages. (U.S. EEOC "Home Care") For more information, see Sexual Harassment.

Prevent Musculoskeletal Disorders

Action Recommendation: Implement a program to prevent musculoskeletal disorders. Provide or help the client arrange for lifts, transfer devices, and adaptive devices as needed to reduce the risk of injury.

Work-related musculoskeletal disorders (MSDs) are a serious concern in home care. In 2015, there were 32.2 cases of occupational MSDs involving days away from work (with or without job restriction or transfer) per 10,000 workers in the home healthcare industry (U.S. BLS "Incidence Rates"). Anyone who lifts or moves a client is at high risk for MSDs; the risk is heightened when staff must perform the task alone, as is usually the case in home care. Other tasks (e.g., bathing or dressing clients, helping with ambulation) can cause MSDs, too. Additionally, clients' homes may be small or crowded, possibly causing staff to hold or work in awkward postures, and beds may not be adjustable. Equipment to aid transfers is usually lacking. (NIOSH)

In many situations, proper body mechanics alone are not enough to totally prevent injury. Fortunately, many devices are available to reduce the potential for injury. They include lifts, draw or slide sheets, slide or transfer boards, rollers, slings, gait belts, toileting or showering chairs, hoists with built-in scales, adjustable beds, raised toilet seats, grab bars, and rotation disks. In each situation, the devices chosen should be suitable to the person using them, the place they will be used (recognizing that in home care, the environment of care is unique to each home), and the tasks they will be used for. (NIOSH) Other factors to consider include whether Medicare, Medicaid, private insurance, or the client will pay for the device and, if the client is obese, the device's weight limit (Rozovsky).

NIOSH's hazard review recommends that organizations take the following steps:

• Consult with a professional with expertise in resident care ergonomics to help identify potential devices and train staff on their use.
• Provide ergonomics training for staff.
• Evaluate each client's care plan to determine whether assistive devices are appropriate.
• Provide appropriate devices when necessary.
• After a device has been put into use, reassess the training, care plan, and device.
• If clients and families resist paying for or installing a device, inform them about the risks involved in moving clients, including the potential for client harm.

The hazard review also recommends that staff do the following when manual client handling is necessary (NIOSH):

• Use assistive devices (if available).
• Move along the side of the bed while performing bedside tasks instead of standing in one spot and bending, twisting, or reaching.
• When manually moving the client, stand as close as possible to him or her without twisting your back. Keep your knees bent and feet apart. To avoid rotating the spine, make sure one foot is in the direction of the move.
• Use a friction-reducing device (e.g., a slip sheet) whenever possible. During lateral transfers, gentle rocking motions may help reduce exertion.
• Put the head of the bed in a flat or down position when pulling a client up in bed. Raising the client's knees and encouraging the client to push (if possible) may also help.

Also see Safe Resident Handling and Movement, as well as Ergonomics and Resident Lifts. NIOSH's Caring for Yourself While Caring for Others, a handbook and other resources for home care workers and clients, offers tips on addressing injuries and pain, cleaning, transferring clients, bathing clients, carrying and loading or unloading laundry, and cooking, among other topics.

Address Unsafe Environmental Conditions in the Home

Action Recommendation: Assess the home for unsafe environmental conditions, and work with clients and external agencies to address them.

Home care staff may be exposed to many unsafe environmental conditions in the home, including dangerous animals or pests, fall hazards, temperature extremes, unsanitary conditions, electrical or other fire hazards, poor lighting, and lack of water or other utilities, to name a few. The discussion Optimize the Environment of Care in Home Care: An Overview reviews other unsafe conditions.

Home care organizations should establish criteria to ensure that the home environment is safe enough for staff to provide care. They should also train staff on what to do if specific hazards are identified.

Assessing the safety of the home environment (see Home Safety Assessment) can help staff identify risks. NIOSH recommends the following:

• Require that animals be kept out of the care area.
• If evidence of pests is seen, discuss control measures with the client.
• If the home is excessively cold, ask the client if it is okay to raise the thermostat.
• If the home is uncomfortably warm and air-conditioning is unavailable or insufficient, open windows, use fans, drink a lot of water, and use cool compresses if needed.
• If the home is unsanitary—
• Bring in only necessary equipment and supplies
• Do not set bags or purses on carpeted flooring
• Consider placing clean, plastic-backed pads under equipment and supplies
• Use nonlatex, disposable gloves and hand sanitizer
• If the home does not have running water or has poor-quality water—
• Consider bringing water if it is necessary for client care
• Use hand sanitizer
• Do not use the toilet if it has insufficient running water

If these or other environmental hazards pose a risk to the client, or if he or she resists (e.g., refusing to implement pest control measures, resisting changing the thermostat), the organization can work with a social services agency to help the client.
Falls are a common source of injury among home care staff. Assessing the safety of the home environment (see Home Safety Assessment) can help staff identify fall risks. NIOSH recommends that organizations train staff about fall protection and steps they can take to identify and reduce fall hazards. NIOSH's recommendations for workers are as follows:

• Wear sturdy, flat shoes with good slip protection.
• Walk slowly on icy or wet surfaces.
• Examine walking paths to the bathrooms, eating areas, and sitting areas.
• Remove or securely tape down rugs using double-sided tape if the client gives you permission.
• Secure cords and other loose materials in the walking path that could cause the client or you to slip, trip, or stumble.
• Use handrails.
• Turn on outside lights before returning to your car in the dark.
• Clean up spills as soon as they happen.

Additionally, NIOSH's Caring for Yourself While Caring for Others offers tips on preventing falls, transferring clients, bathing clients, carrying laundry, and cooking.

Protect Staff from Violence

Action Recommendation: Implement a comprehensive workplace violence prevention program.

Violence poses a risk of injury or even death to home care staff. But even just the threat of violence can adversely affect staff, possibly contributing to stress, low morale, and turnover. Care may suffer if, for example, staff rush through care to reduce interaction with a threatening individual.

Unfortunately, home care staff are at particular risk for violence. In 2014, two home healthcare workers were victims of homicide (U.S. BLS "Fatal Occupational Injuries"). In a survey of 130 staff members of four home visiting programs, respondents were asked whether they had ever experienced certain types of violence; 61.4% said they had been yelled at, shouted at, or sworn at, and 10.8% said they had been physically assaulted by a client or household member. In the preceding year, 5.4% had experienced assault that led to pain that lasted overnight but did not require an emergency department (ED) or physician visit, and 3.8% had experienced assault requiring an ED or physician visit. In the preceding month, 16.2% had been threatened by a client, without physical contact; 8.3% had been subject to unwanted physical contact, without physical injury; and 2.3% had experienced assault resulting in mild soreness of minor injury. (McPhaul et al.)

Training staff to assess violence risk can help them recognize and report potentially dangerous situations. One home care organization developed a tool for assessing the risk for violence before each visit (see Violence Risk Assessment Tool for Home Care) and started a program that included a staff buddy system, sign-in and sign-out forms, paired visits or police escorts by request, and staff education (Lundrigan et al.).

NIOSH offers many recommendations for home care organizations, including the following:

• Create a standard definition of workplace violence, and ask staff to report each dangerous work environment and violent incident, even if they think it is not serious.
• Develop a written plan for ensuring personal safety, reporting violence, and calling the police.
• Train staff to assess safety and to recognize verbal abuse, signs and body language linked with violent assault, illegal drugs and drug paraphernalia, and gang activity.
• Train staff to prevent and manage violent behavior, such as through verbal de-escalation techniques and management of angry clients.
• Do not place staff in assignments that compromise safety. Before each placement, consider doing the following:
• Check with police about the safety of the location.
• For clients with psychiatric illness, ask an expert to assess their potential for violent behavior.
• Have a social worker evaluate the family and home situation.
• Provide security or police support if needed.
• If a placement is unsafe, advise the client on working with people or groups (e.g., social services, police, family members, neighbors) to make the home safer so that care can continue.
• Track staff members' schedules, and give cell phones to all staff on duty.
• Require that all weapons be disabled and stored securely and away from where care is provided.

Home care organizations may wish to consult local police when creating or evaluating policies, procedures, and training on workplace violence. NIOSH's recommendations for workers include the following:

• For high-crime areas, schedule visits during the day and consider working in pairs.
• Always let your employer know where you are and when to expect you to report back.
• Keep all items locked out of sight in the trunk.
• Keep the vehicle's windows rolled up and doors locked at all times.
• Park in well-lit areas and away from objects someone could hide behind.
• Check the area before getting out of the car (and check the car before getting into it).
• Trust your judgment; avoid situations that do not feel right.
• During the visit, use basic safety precautions:
• Be alert.
• Evaluate each situation for possible violence.
• Watch for signals of violent assault (e.g., anger, threatening gestures, signs of drugs or alcohol abuse, presence of weapons).
• Maintain behavior that helps to defuse anger:
• Present a calm, caring attitude.
• Do not match threats or give orders.
• Acknowledge the person's feelings.
• Avoid behaviors that may be interpreted as aggressive (e.g., moving quickly, getting too close, touching unnecessarily, speaking loudly).
• Have a plan for exiting, and keep an exit path open.
• If you feel threatened despite attempts to defuse the situation, leave immediately and call your employer or 911 for help.
• If you are being verbally abused, ask the abuser to stop the conversation.
• If the abuse continues, leave and notify your employer.

For more information, see Resident Aggression and Violence and Workplace Violence Prevention Plan. Also see OSHA's guidelines for preventing workplace violence in healthcare.

Prevent and Address Exposure to Body Fluids

Action Recommendation: Implement programs to prevent sharps injuries and exposure to body fluids, and respond promptly to exposures that do occur.

Home care staff are at risk for exposure to bloodborne pathogens. In a survey of home care workers (mostly RNs), 9.5% said they had acquired hepatitis B infection from a needlestick injury (Kenneley). In another survey of home healthcare RNs, 14% said they had experienced at least one percutaneous injury in the past three years, but 46% of the injuries were not formally reported (Gershon et al.). Nurses are not the only ones at risk. According to a survey of home personal care assistants and RNs, personal care assistants experienced exposure to blood or body fluids roughly one-third as often as nurses. Among respondents who had been exposed in the past year, only 48% of nurses and 17% of personal care assistants formally reported it. (Lipscomb et al.)

Insufficient policies and improper practices may contribute to the problem. In a survey of 30 home health or hospice organizations and 355 nurses employed by them, all employers had a bloodborne pathogen exposure control program. However, only 37% had all elements required by OSHA's bloodborne pathogen standard. For example, only two (7%) ensured that nurses who sustained needlestick injuries were assessed by an occupational health nurse, and only 14% met requirements for personal protective equipment. Many nurses said they did not always have access to safety devices when providing care. Although all employers prohibited needle recapping, 25% of nurses said they recapped needles. (Scharf et al.)

Some factors have been linked to exposure. In the survey of home health RNs, percutaneous injuries were significantly associated with lack of adherence to standard precautions, needle recapping, exposure to stressors in clients' homes (e.g., animal hair, cigarette smoke, excessive dust), exposure to violence, mandatory overtime, and a poor safety climate. (Gershon et al.)

NIOSH's recommendations include the following:

• Ensure that the bloodborne pathogens program meets all the requirements of OSHA's bloodborne pathogen standard.
• Involve staff in the evaluation and selection of safe, effective alternatives to needle devices, and eliminate the use of needle devices whenever possible.
• Analyze sharps-related injuries to identify hazards and injury patterns. If patterns develop, consider—
• Changing work practices to decrease the activities linked to injuries
• Training employees in new ways to do tasks that have caused injury
• Using different needle devices
• Promote work practices that decrease the chance of a needlestick injury.
• Prohibit recapping and bending of used needles.
• Train workers in the safe use and disposal of all types of sharps.
• Provide sharps containers for workers to carry in their vehicles for use when an adequate sharps container is unavailable in the home.
• Train workers to plan for unexpected movement and watch for improperly disposed needles.
• Establish procedures and systems for reporting, timely follow-up, and medical evaluation of all sharps injuries.
• Establish a system to evaluate prevention efforts and provide feedback to workers and management.
• Ensure that the client or other caregivers are trained in basic infection control.
• Provide postexposure evaluation and follow-up, including postexposure prophylaxis when appropriate.

Staff may encounter other risks for bloodborne pathogen exposure in the client's home. For example, bed linens may contain syringes (for self-medication or recreational drug use) or used condoms. The organization may train staff to ensure good lighting, watch for bloodborne pathogen hazards throughout the home, and handle bed linens carefully. (Rozovsky)

Staff who are exposed to blood or body fluids should wash needlesticks and cuts with soap and water; flush splashes to the nose, mouth, or skin with water; and irrigate eyes with clean water, saline, or sterile irrigants. They should report the incident to their supervisor and immediately seek medical treatment. (NIOSH) OSHA's Bloodborne Pathogens Standard, as well as Sharps Injury Prevention Programs and Occupational Exposure to Blood and Body Fluids provide additional information. Additionally, NIOSH's Caring for Yourself While Caring for Others offers tips on handling sharps, handling laundry, and bathing clients.

Reduce Stress among Staff

Action Recommendation: Identify factors contributing to stress among staff, make systems changes to address those factors, and support individual stress management strategies.

The few studies that have examined stress levels in home care staff have found that working in home care can be stressful. NIOSH defines job stress as "the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker." Job stressors include job and task demands (e.g., work overload, time pressure, lack of task control, role ambiguity) and organizational factors (e.g., poor interpersonal relations, lack of support from supervisors or coworkers, unfair management practices). (NIOSH)

Home care staff have reported many of the same stressors as other healthcare workers (e.g., ill and dying clients, workload and time pressures). Additionally, they may face factors that other healthcare workers generally do not face or are more shielded from, such as lack of direct supervision, working alone, unsafe neighborhoods, clients or family members who abuse drugs or alcohol, arguments among the client's family, the stress of spending a lot of time driving in traffic, and risks in the home care environment. Other sources of stress that may be of special concern in regard to home care workers include issues with training and career development and conflict between work and family roles. (NIOSH)

Socioeconomic factors can be a major source of stress. Nearly one in four home care workers lives in poverty. Despite the increasing demand for home care workers, the median hourly wage was $10.11 in 2015—representing a slight decrease, when adjusted for inflation, compared with the hourly wage of $10.21 in 2005. One in two home care workers receives public assistance, and—despite the fact that health insurance coverage has increased—one in four still does not have health insurance coverage. (PHI)

It is not enough to offer only individual stress management strategies and ignore the systems issues that underlie staff members' stress. Approaches may include individual strategies but should favor systems-level strategies. For example, NIOSH's recommendations for home care agencies include the following:

• Provide frequent, quality supervision and support.
• Provide adequate job training and preparation, including continuing education opportunities.
• Hold regular staff meetings in which problems, frustrations, and solutions can be discussed.
• Include lunch breaks and sufficient travel time in workers' schedules, and allow self-paced work.
• Have policies and procedures to ensure staff safety.
• Provide wages and benefits that are competitive with what other service organizations are offering.
• Provide access to an employee assistance program (EAP) or other means of counseling support.
• Consider offering training in topics such as time management, planning skills, or relaxation exercises.

Training to address other factors that may be contributing to stress (e.g., how to respond to abusive or inappropriate language, cultural competence) may also help. (Rozovsky) For more information on stress and burnout, see NIOSH's Caring for Yourself While Caring for Others.

Manage Photography, Social Media, and Professional Boundaries

Action Recommendation: Evaluate policies addressing photography, social media use, use of personal electronic devices, and professional boundaries.

Photography and social media use—by staff, clients, or the organization itself—are prime concerns in home care. Risks abound from potential violations of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, lawsuits from clients (e.g., alleging invasion of privacy), lawsuits from home care workers (e.g., alleging interference with labor protections or discrimination), and negative impact on the organization's reputation. Therefore, home care organizations must develop sound policies on photography, social media use, and use of personal electronic devices. See Photography, Filming, and Other Imaging of Residents and Social Media in Healthcare, as well as Personal Electronic Devices in Healthcare, for more information on these topics.

The issue is not restricted to staff members' use of photography and social media. Clients' use of photography or social media may pose risks to staff. For example, a photo of a staff member giving an injection could advertise the fact that the staff member has access to drugs. The organization may wish to have a policy prohibiting clients and family members from posting photos or other likenesses of staff in social media. (Rozovsky)

Because home care staff visit clients in their homes, they may develop personal relationships with clients or family members, potentially leading to behaviors that cross professional lines. In cases in which a client has few loved ones, staff risk client dependence on them for companionship or help. Thus, staff must monitor their relationships with clients and maintain professional boundaries. (Anewalt)

Behaviors that cross professional boundaries include the following (Anewalt):

• Giving the client a personal phone number
• Visiting or calling the client outside work hours or providing care outside the plan of care
• Doing housework or running errands for the client
• Attending social events with clients or families
• Giving gifts, meals, or clothes to the client
• Starting unsolicited discussion with the client about religious beliefs

Additionally, clients or family members sometimes seek to give money or gifts to home care workers. This situation raises several concerns. For example, family members may question whether the worker solicited the gift. Or the client or a family member may later accuse the worker of theft, particularly if the client has cognitive impairment.

To maintain a professional relationship with clients, staff should define their role as a provider of healthcare or personal care and explain the boundaries of their roles at the first meeting with the client. Additionally, staff should keep the focus on the client during visits. (Anewalt)

Home care organizations should develop policies and procedures that define professional boundaries and should either set limits on the acceptance of gifts from clients (e.g., only small items such as flowers) or prohibit the acceptance of gifts. Organizations may also encourage staff to maintain a healthy balance between their work and personal life, such as by taking vacations or attending "care for the caregiver" in-service meetings. (Anewalt)

Manage Driving-Related Risks

Action Recommendation: Manage driving-related safety and liability risks through driver and vehicle safety programs and appropriate insurance coverage.

Vehicles are a common source of home care worker injury. In 2015, transportation incidents were the cause of 5.7 cases of nonfatal occupational injury involving days away from work per 10,000 home healthcare workers (U.S. BLS "Incidence Rates"). In 2014, six home healthcare workers—nearly half of the 13 who died on the job—died in roadway motor vehicle incidents (U.S. BLS "Fatal Occupational Injuries").

Driving also poses a risk for death or injury of others, property damage, and traffic violations. Additionally, accidents that occur on the staff member's way to the first client of the shift or home from the last client may represent a gray area of liability, as it could be argued that the staff member was on the job at the time rather than just on the way to or from work. To reduce such risks, the organization may wish to have staff start and end the day by checking in and out at the agency's office.

NIOSH recommends that home care organizations do the following:

• Mandate and enforce seatbelt use.
• Ensure that staff who drive for the job have valid driving licenses.
• Include fatigue management in safety programs.
• Ensure staff training on driving specialized vehicles (if used).
• Avoid requiring staff to drive irregular or very long hours.
• Ensure that employer-owned vehicles are serviced regularly.
• Consider providing vehicles that offer the highest occupant protection in the event of a crash.
• Provide maps or a global positioning system (GPS) device to staff.

The organization should let prospective staff know that it will check driving records before hire and periodically thereafter. Organizations should be familiar with their state's categories of driver licenses, including commercial and noncommercial types, and insurance requirements for each. If staff will use their own vehicles, it should require proof of insurance, current auto registration, and inspections.

Training can address things staff can do to reduce risks, such as wearing seatbelts, avoiding distractions (e.g., cell phone use, eating or drinking, adjusting the radio), having the car checked and serviced regularly, and carrying an emergency kit (NIOSH). Additionally, staff should be instructed not to drive to a client's home while the roads are hazardous due to weather conditions or poor visibility; they should wait until the hazard is gone. Contracts with clients should include a clause indicating that weather-related delays may occur, and the organization should have a process for notifying clients of weather-related delays. (Rozovsky)