Referral Information
Serenity Care Agency accepts referrals from any source, including hospitals, community organizations, nursing agencies, authorized practitioners, patients/families, third-party payers, and DSS, as long as basic information about the patient and the need for service is available. The referring source is requested to provide:
- Patient’s name and address
- Insurance coverage or payer
- Medical diagnosis
- Type and level of service required
- Authorized practitioner’s name and address
- Referrer’s name, title, and phone number
- Name and phone number of the primary caregiver and emergency contact
Serenity Care Agency accepts referrals seven (7) days a week. Referrals can be faxed twenty-four (24) hours a day. Faxed referrals will be acknowledged on the following business day.
Referrals will be reviewed for completeness. If necessary, the Home Care Coordinator or RN will contact the referrer or physician to obtain additional information. Referrals are accepted once all required information is received.
Agency nursing staff will be assigned to perform the in-house patient assessment within 24 hours of referral acceptance. The decision to accept the patient for care is made after the nursing assessment.
If the agency cannot provide services in a timely manner or if specific services are unavailable in the required amount, frequency, or duration, the referring source will be informed within 24 hours of receiving the referral.
Policy: Admission
Purpose: To ensure that the agency admits only those patients whose healthcare needs can be safely addressed at home with the help of agency personnel and services. This decision will be made by a registered professional nurse after a patient assessment, which will consider the type and level of services needed, the adequacy of the home environment, the involvement of family or informal support, and the availability of agency personnel.
Admission
A patient will be admitted for healthcare services after an assessment by a registered nurse or an individual directly supervised by the RN determines if the patient’s needs can be safely and adequately met by the agency.
Decisions about patient admission are based on the patient’s health and safety, as well as the safety of agency staff. The agency is dedicated to delivering ordered care and services while respecting the patient’s wishes as much as possible. Patients are accepted for care regardless of race, color, religion, age, sex, national origin, or disability.
Criteria for Admission
The patient is either receiving regular medical care or is prepared to seek care from a licensed authorized practitioner who will provide ongoing medical supervision and treatment orders.
A patient diagnosed with active pulmonary tuberculosis will be considered for admission only if the following conditions are met before the patient’s assessment:
- The patient has been on an anti-tuberculin regimen for at least two weeks
- The patient demonstrates clinical improvement
- Stained smears of three consecutive sputum samples are AFB negative
As an outcome of the patient assessment, the nurse will identify and document:
- The patient’s need for services and the type of care to be provided
- The need for additional assessment
- Available, willing, and capable caregivers
- Educational needs of the patient, family, or support system
- Potential victims of abuse
- Discharge planning and/or ongoing care needs
Development of the Care Plan
A written plan of care, based on a patient assessment by a registered nurse, is created and implemented for each patient admitted for home care services. This nursing care plan includes the identification of problems, needs, goals, specific planned actions, and the type and frequency of healthcare services to be provided.
The plan of care is shared with all staff involved in the patient’s care, including those providing contracted services, to ensure appropriate coordination and continuity.
For patients needing skilled care, the plan of care will include a problem list that aligns with the physician’s orders and must be completed within five working days. The problem list includes goals and outcome criteria for each issue, along with specific interventions, including their frequency and duration.
Please use the form below to send us your referrals.