1557 Winchester Ave, Ashland, KY 41101. Local Phone: 606 ...

1557 Winchester Ave, Ashland, KY 41101. Local Phone: 606-325-1115. Toll-free: 888-446-6348

5528 MacCorkle Ave SE, Suite 101, Charleston, WV 25304. Local Phone: 304-341-0300. Toll-free: 888-446-6348

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Contents

INFUSION PROTOCOLS .............................................................................................. 3

RECOMMENDED FLUSHING PROTOCOL - ADULT ...................................................... 4

RECOMMENDED FLUSHING PROTOCOL - PEDIATRIC ................................................ 6

ADULT PATIENT TEACHING GUIDES .......................................................................... 8

PICC Flush ........................................................................................................ 8

Elastomeric Ball ................................................................................................ 9

Elastomeric Ball (Continuous Infusion) .......................................................... 10

IV Push Syringe .............................................................................................. 11

Mini-Bag Plus, Mini-Bag “IV Piggyback,” or Premixed IV Bag ......................... 12

Continuous Antibiotic or Pain Management on a CADD Solis Pump .............. 19

Hydration on a CADD Solis Pump ................................................................... 21

Hydration on a Z-800 Pump ........................................................................... 24

Home Medication Mix ................................................................................... 27

PEDIATRIC PATIENT TEACHING GUIDES .................................................................. 29

PICC Flush ...................................................................................................... 29

Elastomeric Ball .............................................................................................. 30

TOTAL PARENTERAL NUTRITION (TPN) ................................................................... 31

ENTERAL THERAPY OVERVIEW ............................................................................... 35

Gravity Enteral Nutrition ................................................................................ 36

Bolus/Syringe Fed Enteral Nutrition ............................................................... 37

Enteral Nutrition Delivered via Infinity Pump ................................................ 38

Enteral Nutrition Delivered via EntraFlo H20 pump ....................................... 39

Enteral Nutrition Delivered via Kangaroo Joey Pump .................................... 40

Enteral Nutrition Tube Site Care .................................................................... 41



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COMPANY OVERVIEW ............................................................................................. 42

PATIENT’S RIGHTS AND RESPONSIBILITIES .............................................................. 43

NOTICE OF PRIVACY PRACTICES .............................................................................. 44

INFECTION CONTROL AT HOME (IV THERAPY) ........................................................ 51

DISPOSABLE ITEMS & EQUIPMENT ......................................................................... 53

SHARP OBJECTS ...................................................................................................... 53

SPILLS IN THE HOME ............................................................................................... 54

SANITATION ............................................................................................................ 54

TIPS ON MEDICAL EQUIPMENT SAFETY .................................................................. 54

HOW TO PLACE A PRESCRIPTION ORDER ................................................................ 55

HOW TO CHECK ON A PRESCRIPTION ORDER ......................................................... 55

HOW TO HANDLE ADVERSE REACTIONS ................................................................. 55

HOW TO ACCESS MEDICATIONS IN CASE OF AN EMERGENCY OR DISASTER .......... 56

HOW TO HANDLE MEDICATION AND PRODUCT RECALLS ....................................... 56

HOW TO DISPOSE OF MEDICATIONS ...................................................................... 56

PROTOCOL FOR RESOLVING PATIENT COMPLAINTS ............................................... 57

MEDICARE DMEPOS SUPPLIER STANDARDS ........................................................... 58

CADD SOLIS INFUSION PUMP LIMITED WARRANTY ................................................ 59

ZYNO MEDICAL Z-800 STATIONARY PUMP LIMITED WARRANTY ............................ 60

KANGAROO JOEY ENTERAL PUMP LIMITED WARRANTY ......................................... 60

ENTRALITE INFINITY ENTERAL PUMP LIMITED WARRANTY .................................... 61

ENTRAFLO H20 ENTERAL PUMP LIMITED WARRANTY ............................................ 61



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INFUSION PROTOCOLS TYPE THERAPY/ACCESS FREQUENCY

Tubing Change ABX/Hydration Gravity/Stationary Pump

Every 24 hours

Ambulatory Pump Every 24 hours or with bag change TPN, IVIG, Solumedrol Every 24 hours

Blue end cap change Every dose Injection cap change Every week and/or with blood draws

Central Line dressing change Chloraprep or Alcohol/Povidone Iodine

Gauze M-W-F or, as needed if soiled Transparent Every week or, as needed if soiled

Epidural dressing change At least 2x/week or every 4th day, as needed if soiled

IV Restart (Peripheral) Peripheral Dressing Change

Every 48-72 hours or longer with MD order With re-stick and as needed if soiled

SQ Infusion SQ dressing change

Every 48-72 hours or longer with MD order With needle change or, as needed if soiled

Port Access With infusion Every week

Without infusion Every month Battery change Ambulatory Pump TPN: Daily, if Volume is greater than

2000 mL may change 2x/day ABX: Every 48 hours

Epidural: Every 2-4 days Pain: IV/SubQ=1-2 x/week

Chemo: with each cassette/bag change



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RECOMMENDED FLUSHING PROTOCOL - ADULT INFUSION ACCESS FLUSHING DRESSING CHANGE EXTENSION &

INJECTION CAP CHANGE

BLOOD SAMPLING

Peripheral or Saline Lock

NS 3mL before & after medications, at least every 12-24 hours & as needed

Every 48-72 hours & as needed

Every 48-72 hours & as needed

N/A

PICC (This includes Solo & BioFlo)

NS 10mL before & after medications, every 12 hours & as needed Heparin 10 unit/mL 3mL after medications, every 12 hours & as needed

Transparent- weekly & as needed Gauze-3 times per week or every 48 hours & as needed

Every week, with blood draws & as needed

Hub to Hub- Flush with 10-20 mL NS Discard 6 mL blood Obtain blood sample Flush with NS 10-20 mL Flush with Heparin 10 unit/mL 3 mL

Midline – EXCEPT BARD PowerGlide Midline, BARD Provena Midline, BARD Poly Midline, BARD Per-Q Cath


Transparent-weekly & as needed Gauze-3 times per week or every 48 hours & as needed

Every week & as needed

N/A ABSOLUTELY NO WITHDRAW FROM CATHETER OR THE ADMINISTRATION OF CATHFLO!

BARD PowerGlide Midline, BARD Provena Midline, BARD Poly Midline, BARD Per-Q Cath




Hub to Hub- Flush with NS 10-20 mL Discard 6 mL blood Obtain blood sample Flush with NS 10-20 mL Flush with Heparin 10 unit/mL 3mL

Groshong Power PICC Groshong PICC Groshong NXT PICC

NS 10mL before & after medications, weekly & as needed NO HEPARIN REQUIRED



Hub to Hub- Flush with NS 10-20 mL Discard 6 mL blood Obtain blood sample Flush with NS 10-20 mL

Apheresis (POST-TRANSPLANT)

NS 10mL before & after medications, as needed to assess or restore patency. Heparin 100 unit/mL 2mL after medications, every 24 hours & as needed




Dialysis Catheter (Refer to additional policy & procedure provided upon request)

N/A N/A N/A N/A



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Central Line Subclavian/Jugular


Transparent dressing weekly & as needed Gauze-3 times per week or every 48 hours & as needed



Hickman Hohn PowerLine





Groshong Catheter (Not PICC)

NS 10mL before & after medications, weekly & as needed NO HEPARIN REQUIRED!



Hub to Hub- Flush with NS 10-20 mL Discard 9 mL blood Obtain blood sample Flush with NS 10-20 mL

Implanted Port NS 10mL before & after medications, daily while accessed, at least every 4-8 weeks when not in use & as needed Heparin 100 unit/mL 5mL after medications, daily while accessed, at least every 4-8 weeks when not in use & as needed

Transparent-weekly while in use Gauze-3 times per week or every 48 hours & as needed while in use

Every week, with blood draws & as needed while in use


Extended Dwell Catheter (Can stay in

up to 29 days) PowerGlide Pro PowerGlide AccuCath

NS 10mL before & after medications, every 12 hours & as needed Heparin 10 unit/mL 3mL after meds, every 12 hours & as needed



N/A

NOTE: THESE ARE INFUSION SOLUTIONS’ RECOMMENDED PROTOCOLS. PLEASE FOLLOW YOUR PHYSICIAN’S ORDERS IF DIFFERENT FROM THE PRECEDING PROTOCOLS.

NOTE: IF PATIENT HAS CONTINUOUS TPN INFUSING, FLUSH WITH 20 ML NS BEFORE BLOOD SAMPLING

NOTE: WV MEDICAID WILL ONLY COVER HEPARIN 100 unit/mL SYRINGES; A VARIANCE IN THE FLUSHING PROTOCOL SHOULD BE NOTED WITH THIS COVERAGE.

NOTE: IF SUPPLIES ARE PROVIDED BY YOUR HOME HEALTH AGENCY AND NOT INFUSION SOLUTIONS, SWAB CAP MAY NOT BE PROVIDED. IT IS ACCEPTABLE PRACTICE TO OMIT SWAB CAP AND SCRUB HUB WITH ALCOHOL SWAB FOR 15 SECONDS.



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RECOMMENDED FLUSHING PROTOCOL - PEDIATRIC

INFUSION ACCESS FLUSHING GUIDELINES

Age: 0-6 years Age: 7-17 years

Tunneled Catheter Broviac

3mL 0.9% Sodium Chloride before & after medications, every 24 hours & as needed. 1 mL Heparin 10 unit/mL after medications, every 24 hours & as needed. Following blood draw: 5mL 0.9% Sodium Chloride. 2mL Heparin 10 unit/mL.

5mL 0.9% Sodium Chloride before & after medications, every 24 hours & as needed. 3mL Heparin 10 unit/mL after medications, every 24 hours & as needed. Following blood draw: 10mL 0.9% Sodium Chloride. 5mL Heparin 10 unit/mL.

Groshong Tip Catheters

Generally, not used in pediatric patients. 10mL 0.9% Sodium Chloride before & after medications, at least every 7 days, & as needed. Following blood draw: 20mL 0.9% Sodium Chloride. Does not require Heparin!

Hohn Catheters Generally, not used in pediatric patients. 5mL 0.9% Sodium Chloride before & after medications, at least every 7 days, & as needed. 5mL Heparin 10 unit/mL after medications, at least every 7 days. Following blood draw: 10mL 0.9% Sodium Chloride. 5mL Heparin 10 unit/mL.

PICC 1.9 FR/2FR VYGON FIRST CATH L-CATH

3mL 0.9% Sodium Chloride before & after medications, as needed to assess/restore patency. 2mL Heparin 10 unit/mL after final Normal Sodium Chloride (Saline) Flush, every 12 hours & as needed **NO BLOOD DRAW!**

5mL 0.9% Sodium Chloride before & after medications, as needed to assess/restore patency. 2mL Heparin 10 unit/mL after final Normal Sodium Chloride (Saline) Flush, every 12 hours & as needed **NO BLOOD DRAW!**

PICC 3FR/4FR/5FR & Extended Dwell Cath (EDC) First Cath PASV with clamps Arrow L-Cath PowerGlide/AccuCath

5mL 0.9% Sodium Chloride before & after medications, as needed to assess/restore patency. 3mL Heparin 10 unit/mL after final Normal Sodium Chloride (Saline) Flush, every 12 hours & as needed. Following blood draw: 5mL 0.9% Sodium Chloride 3mL Heparin 10 unit/mL. **NO BLOOD DRAW FROM EDC**

10mL 0.9% Sodium Chloride before & after medications, as needed to assess/restore patency. 3mL Heparin 10 unit/mL after final Normal Sodium Chloride (Saline) Flush, every 12 hours & as needed. Following blood draw: 10mL 0.9% Sodium Chloride 5mL Heparin 10 unit/mL. **NO BLOOD DRAW FROM EDC**

Implanted Port

3mL 0.9% Sodium Chloride before & after medications, daily if accessed. 3mL Heparin 10 unit/mL after medications, daily if accessed. Maintenance: 5mL Heparin 10 unit/mL monthly & upon de-access. Following blood draw: 5mL 0.9% Sodium Chloride. 5mL Heparin 10 unit/mL.

5 mL 0.9% Sodium Chloride before & after medications, daily if accessed. 3 mL Heparin 100 unit/mL after medications, daily if accessed. Maintenance: 5mL Heparin 100 unit/mL monthly & upon de-access. Following blood draw: 10mL 0.9% Sodium Chloride. 5mL Heparin 100 unit/mL.



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Additional Pediatric Guidelines as Follows:

1. CVL/PICC dressings will be changed weekly and as needed if soiled.

2. Microclave (Injection Cap) change weekly and with blood draw.

3. DO NOT use Chloraprep/Chlohexadine on infants less than 2 months of age.

4. If a child is greater than 2 months of age and allergic to Chloraprep, use 3 Alcohol Padsticks and 3 Povidone swabsticks.

5. If child is allergic to POVIDONE, CHLORAPREP OR ALCOHOL, may use HYDROGEN PEROXIDE.

6. TUBIFAST to all pediatric patients unless requested otherwise.

7. PRESERVATIVE FREE Pre-filled Normal Saline and Heparin must be used in infants less than 3 months of age.

8. ELASTOMERIC DEVICES will be utilized in all pediatric patients 17 years and younger unless otherwise specified. For example: Drug stability; other options offered (PUMP).

NOTE: THESE ARE INFUSION SOLUTIONS’ RECOMMENDED PROTOCOLS. PLEASE FOLLOW YOUR PHYSICIAN’S ORDERS IF DIFFERENT FROM THE PRECEDING PROTOCOLS.



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ADULT PATIENT TEACHING GUIDE

PICC Flush Supplies needed:

1 Sodium Chloride (Saline) Flush 1 Heparin Flush 1 Swab Cap 2 to 4 Alcohol Pads

Please WASH HANDS!

Clean surface of work area with an Antibacterial Wipe or Alcohol.

Place supplies on a hard surface work area.


Step one: Remove and discard Swab Cap. Clean end of catheter with an alcohol swab for 15 seconds.

Step two: Clear air out of Sodium Chloride (Saline) syringe. Using a pulsing technique when flushing with Sodium Chloride (Saline).

Step three: Clean end cap of catheter with an alcohol swab for 15 seconds.

Step four: Clear air out of Heparin syringe. Using a pulsing technique when flushing with Heparin.

Step five: Screw on new Swab Cap on end of catheter.

Follow this procedure with each lumen of your PICC or Midline every 12 hours as directed.



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Elastomeric Ball Supplies needed:

2 Sodium Chloride (Saline) Flushes 1 Heparin Flush 1 Swab Cap 4 Alcohol Pads

Take antibiotic out of the refrigerator as directed per label before taking the medication.

Please WASH HANDS!




Step one: Remove Swab Cap and clean end cap of catheter with an alcohol swab for 15 seconds. Open clamp on IV line.

Step two: Flush line with Sodium Chloride (Saline) flush

Step three: Clean end of catheter with an alcohol swab and connect antibiotic. Open clamp on med ball.

Step four: Check label on bag to determine how long medication will take to infuse.

Step five: At the end of the infusion time, close clamp, disconnect ball and discard in trash.

Step six: Clean end of catheter and flush with Sodium Chloride (Saline) flush.

Step seven: Clean end of catheter and flush with Heparin.

Step eight: Screw new Swab Cap on end of catheter.

*If your IV line has more than one lumen, flush “unused” or “other” lumen(s) with one Sodium Chloride (Saline) flush and one Heparin flush every 12 hours as directed on page 8 “ADULT PATIENT TEACHING GUIDE PICC flush.” *



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Elastomeric Ball (Continuous Infusion) Supplies needed:

1 Sodium Chloride (Saline) Flush 2 Alcohol Pads


Please WASH HANDS!



Unclamp tubing on ball to ensure (medication) fluid is through the line and begins to drip out before attaching.

Step one: At ______________O’clock scrub end of IV access with an alcohol pad for 15 seconds.

Step two: Flush line with Sodium Chloride syringe using push/pause method. Remove syringe and discard.

Step three: Scrub end of IV access with an alcohol pad for 15 seconds and connect new ball. Open clamp.

Step four: The medication will take about 24 HOURS to infuse.

Step five: Clamp line and disconnect ball at ______________ O’clock the next day.

Step six: Repeat steps 1-3.




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IV Push Syringe Supplies needed:

2 Sodium Chloride (Saline) Flushes 1 Heparin flush 4 Alcohol Pads 1 Swab Cap

Please take antibiotic out of the refrigerator 1 hour before taking the medication.

Please WASH HANDS!




Step one: Clean end cap of catheter with an alcohol swab for 15 seconds. Open Clamp on PICC line.

Step two: Remove air as instructed. Flush line with 10 mL Sodium Chloride (Saline) Flush using a pulsing technique.

Step three: Clean end of catheter with an alcohol swab and connect antibiotic syringe.

Step four: Slowly push medication into catheter over 3-5 min.

Step five: Remove syringe and discard in trash.

Step six: Clean end of catheter with an alcohol swab for 15 seconds, remove air from Sodium Chloride (Saline) Flush, then flush with Saline using a pulsing technique.

Step seven: Clean end of catheter with an alcohol swab for 15 seconds remove air from syringe and flush with Heparin using a pulsing technique. Close clamp on PICC line.




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Mini-Bag Plus, Mini-Bag “IV Piggyback” or Premixed IV Bag Supplies needed:

2 Sodium chloride (Saline) flushes 1 Heparin flush 1 Swab Cap 4 Alcohol Pads Mini-Bag Plus with Medication Vial attached, or Mini-Bag “IV Piggyback,” or Premixed IV Bag Dial-a-flow tubing (tubing should be used for all doses of same medication for 24-hour period) Blue End Caps (for tubing if multiple medication doses given in 24-hour period)

Please WASH HANDS!




MIX ANTIBIOTIC MINI-BAG (SKIP TO “PRIME TUBING” SECTION FOR MINI-BAG [IVPB] OR PREMIXED BAG)

To mix medication in the Mini-Bag Plus, you will need to break the seal between the bag and the vial, which contains your medicine in a powdered form. Bend the sealed area up and down to break this seal.



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Hold the bag with the vial pointing down. Squeeze the solution from the bag into the vial until it is ½ full. You will need to squeeze and let go of the IV bag several times until the vial is ½ full. Shake the vial to mix the drug.

Once the powder is mixed and is in liquid form, turn the bag upside down and squeeze the bag. This forces air to go into the vial.

You will need to squeeze and let go of the IV bag several times to get all the medication out of the vial and back into the bag. Make sure the solution is mixed well by shaking the IV bag so the medication is fully dissolved. Do not remove the vial.



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PRIME TUBING WITH MEDICATION

Close the dial on the IV tubing to the “OFF” position

Remove the plastic seal from the medicine bag.



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The IV tubing has a spike. Remove the cover from the spike and insert the spike into the bottom of the medication bag where the seal was removed. Hang the bag on the IV pole or

door hanger through the loop on the top of the IV bag. *Be sure that medication bag is hanging at least 3 feet above patient’s heart, otherwise medication may not infuse. *



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Fill the drip chamber on the IV tubing with the medication. Squeeze the drip chamber with your thumb and index finger until the drip chamber is ½ full.

Open the IV tubing dial until you see fluid in the IV tubing. If a flow does not start squeeze the IV bag. Leave the IV tubing dial open until you see fluid coming through the end of the tubing.



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Once medicine is coming out of end of tubing close the dial to the “OFF” position.

Close clamp on IV tubing. This is called priming the tubing. Replace cap to IV tubing once tubing is primed.



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MEDICATION ADMINISTRATION & FLUSHING LINE

Step one: Clean end cap of catheter with an alcohol swab for 15 seconds.

Step two: Flush line with sodium chloride (Saline) Flush.

Step three: Remove Swab Cap from end of IV catheter, clean with alcohol swab and connect antibiotic, set rate as directed on label and/or nurse/patient instruction sheet on dial a flow tubing. Open clamp.

Step four: The medication will infuse as directed per the label.

Step five: When the bag is empty, close clamp and disconnect the tubing from the IV access. The tubing is to be used for all doses of the same medication for a 24-hour period then discarded in the regular trash. If you have three doses per day, you use the same tubing for all three doses of the same medication. *If using tubing for multiple doses in 24 hours, screw Blue End Cap onto end of dial a flow tubing. *

Step six: Clean end of catheter and flush with Sodium Chloride (Saline) Flush.

Step seven: Clean end of catheter and flush with Heparin





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Continuous Antibiotic or Pain Management on a CADD Solis Pump Supplies needed:

1 Sodium Chloride (Saline) Flush 4 Alcohol Pads Tubing for pump

Please WASH HANDS!



PREPARING THE BAG OR CASSETTE

Remove the (BAG) tubing from the package. Close all clamps. Remove cap from the administration set spike. Remove tab from the MEDICATION bag while keeping both ends sterile. Insert spike into the bag port.

*OR*

Remove the (CASSETTE) tubing from the package. Attach BLUE end to CASSETTE and the PURPLE end goes to the patient.

ATTACHING THE TUBING TO THE PUMP

1. Check the right side of the pump: pull lever down on the CADD Solis.

2. Before attaching the clear “passthrough” cassette to the pump, remove the blue clip. The tubing is now clamped closed. The cassette will attach directly to the pump.

3. Attach the 2 cassette hooks into the hinge pins on the bottom of the pump while sliding the other end up into the rectangle hole.

4. Place the pump upright on a firm surface. Press down so the clear “passthrough” cassette or the actual cassette fits tightly against the pump. The clear piece or cassette will “click” into place.

5. Raise lever into place on the CADD Solis pump.

PRIMING THE ADMINISTRATION SET

1. Place 4 NEW – “AA” batteries in the top of the pump as shown at least EVERY 48 HOURS.

2. Turn pump ON by pressing the ON/OFF button on the RIGHT side of the pump.

3. Loosen the cap on the end of the tubing.

4. Press the Down “Arrow” to highlight “Prime”, then press SELECT. Enter three-digit CODE by using Up/Down “Arrows” and pressing SELECT. (Call Infusion Solutions if code needed.)



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5. Press button below the word PRIME. Press only 1 time. PUMP will stop priming at times. Answer the question “Continue priming?” by pressing the button below the words “Yes” or “No”.

6. If the tubing has a filter, make sure the filter is hanging downward during priming.

7. Re-clamp the tubing if applicable. Press button under the work “Back” twice to get back to the main screen.

STARTING THE INFUSION

1. Scrub the hub on the injection cap for 15 seconds. Flush with 10mL Sodium Chloride.

2. Scrub the hub on the injection cap again for 15 seconds.

3. Remove the sterile cap from the end of the tubing; attach tubing to injection cap by pushing and twisting at the same time. Open all clamps.

4. Press the START button. Press the button below the word “Yes” to start pump. The screen will turn green and a picture of a man running will be on the display as well.

COMPLETING THE CURRENT INFUSION and REATTACHING NEW BAG OR CASSETTE

When infusion is complete, the screen will turn red with a Stop Sign and a Hand on the screen. At this time, you may disconnect.

1. Have the Sodium Chloride ready before the end of the infusion.

2. PUSH the START/STOP button to only Stop pump. Press “NO” to avoid powering down. May leave batteries in pump and re-use for up to 48 hours.

3. Clamp the administration set (tubing).

4. Unscrew the administration set from the injection cap. Remove the clear “passthrough” cassette from the pump or cassette itself by lowering the lever and then pushing downward until the cassette releases.

5. Scrub the injection cap for 15 seconds.

Flush with 10mL of Sodium Chloride; REPEAT PREVIOUS STEP and then press TASKS then RESET RESERVOIR VOLUME then YES then VIEW DELIVERY SETTINGS; followed by pressing BACK twice then START PUMP.



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Hydration on a CADD Solis Pump Supplies Needed:

1 or 2 Sodium Chloride (Saline) Flush 1 Heparin Flush 1 Swab Cap 4 Alcohol Pads Tubing for pump Syringes w/needles (if additives are required) Sharps container (if additives are required)

Please WASH HANDS!




TIPS!

***Store fluids and/or additives as indicated on the medication labels. If fluids are to be stored in the refrigerator, then remove from refrigerator approximately 4 hours before hooking up infusion to allow solution to warm to room temperature. ***Use tubing and all other supplies ONLY ONCE.

PREPARING THE FLUID BAG **SKIP OVER THIS SECTION IF NO ADDITIVES ARE ORDERED**

1. Prepare the additives as directed. When removing any cap from the additive, scrub the top of the vial for 15 seconds with an alcohol pad. You may need to attach the needle to the syringe. You will need to choose the correct size syringe for each additive. You will always scrub the injection port to the Fluid bag for 15 seconds with an alcohol pad before injecting any additive.

2. There are 2 vials of Multivitamins (Brand name: Infuvite or MVI) – 1 Blue top and 1 White or Yellow top.

i. Use the same needle and syringe to draw up from both vials.

ii. Scrub the injection port on the Fluid bag.

iii. Inject Vitamins into the Fluid bag.



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3. If Insulin is ordered to be added to the Fluid bag:

i. Draw up Insulin from vial with ORANGE CAPPED Insulin syringe.

ii. Check Insulin dose with another person.

iii. Scrub injection port on the Fluid bag.

iv. Inject Insulin into the Fluid bag injection port.

*If there are any other medications to be added, follow the same procedures in step 1 plus directions on additive label for correct dose/volume.

4. Discard all syringes and needles into the Sharps container.

5. Mix the solution by holding the bag at both ends and gently rocking it back and forth about 4-5 times. After mixing, the solution should look completely clear or yellow if you have added Vitamins. If your solution has floating sediment or particles of any kind, DO NOT USE THE BAG AND CALL INFUSION SOLUTIONS IMMEDIATELY!

ATTACHING THE FLUID BAG TO THE PUMP

1. Remove the Tubing from the package. Close all clamps. Remove cap from the administration set spike. Remove tab from the Fluid bag while keeping both ends sterile. Insert spike into the bag port.

2. Check the right side of the pump: pull lever down on the CADD Solis.

3. Before attaching the clear “passthrough” cassette to the pump, remove the blue clip on top of cassette. The tubing is now clamped closed.

4. Attach the 2 cassette hooks into the hinge pins on the bottom of the pump while sliding the other end up into the rectangular hole.

5. Place the pump upright on a firm surface. Press down so the clear “passthrough” cassette fits tightly against the pump. The clear piece will “click” into place.


PRIMING THE ADMINISTRATION SET

1. Place 4 NEW – “AA” batteries in the top of the pump as shown at least EVERY 48 HOURS.






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5. Press button below the word PRIME. Press only 1 time. PUMP will stop priming at times. Answer the question “Continue priming?” by pressing the button below the words “Yes” or “No.”

6. Make sure the filter is hanging downward during priming.

7. Re-clamp the tubing.

8. Press button under the word “Back” twice to get back to the main screen.




3. Remove the sterile cap on the Fluid tubing; attach tubing to injection cap by pushing and twisting at the same time.

4. Open all clamps.


COMPLETING THE INFUSION

When infusion is complete, the screen will turn red with a Stop Sign and a Hand on the screen. At this time, you may disconnect.

1. Have the Sodium Chloride and/or Heparin ready before the end of the infusion.

2. PUSH the START/STOP button to Power down. Press button below the word “YES.” May leave batteries in pump and re-use for up to 48 hours.


4. Unscrew the administration set from the injection cap. Remove the clear “passthrough” cassette from the pump by lowering the lever and then pushing downward until the cassette releases.

5. Scrub the injection cap for 15 seconds. Flush with 10mL of Sodium Chloride; followed by Heparin if applicable.

***If Fluids are continuous, may flush with only 10mL Sodium Chloride before reconnecting new bag and tubing***. REPEAT PREVIOUS STEPS and then press TASKS then RESET RESERVOIR VOLUME then YES then VIEW DELIVERY SETTINGS; followed by pressing BACK twice then START PUMP. *If your IV line has more than one lumen, flush “unused” or “other” lumen(s) with one Sodium Chloride (Saline) flush and one Heparin flush every 12 hours as directed on page 8 “ADULT PATIENT TEACHING GUIDE PICC flush.” *



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Hydration on a Z-800 Pump Supplies Needed:

1 or 2 Sodium Chloride (Saline) Flush 1 Heparin Flush 1 Swab Cap 4 Alcohol Pads Tubing for pump

Please WASH HANDS!




PREPARING/PROGRAMMING PUMP

1. Power the pump on by pressing the ON/OFF button for 2 seconds located on the left lower corner of the pump.

2. If you are NOT changing the rate or volume of original order choose “RESUME INFUSION.” SKIP STEP 3; MOVE ON TO NEXT SECTION “PRIMING TUBING, PREPARING FLUID BAG AND LOADING TUBING INTO PUMP”

3. If the rate or volume of original order needs changed follow directions below.

i. Select “New Infusion” then “Program”

ii. Select #1 “Continuous Mode R/V.” This pump will only be used in this mode.

iii. Using the UP/DN arrow select the parameter, then modify the parameter using the data entry buttons.

iv. Enter the primary rate of _____________ mL/hr.

v. Using the UP/DN arrow select parameter, then modify using the data entry buttons.

vi. Enter the primary VTBI of _____________ mL.



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PRIMING TUBING, PREPARING THE FLUID BAG AND LOADING TUBING INTO PUMP

1. Prime the tubing.

i. Close the roller clamp.

ii. Spike and hang bag: Remove the Tubing from the package. Remove cap from the administration set spike. Remove tab from the Fluid bag while keeping both ends sterile. Insert spike into the bag port.

iii. Fill drip chamber of tubing 2/3 full.

iv. Open the roller clamp mid-way.

v. Prime rest of line by gravity.

vi. Close roller clamp to prepare for loading pump.

2. Load tubing into pump.

i. Lift lever and open door.

ii. Push tubing into the tubing guides from the top of the pump to the bottom.

iii. Align tubing on top of the tubing guide at the Free Flow Clamp (Do not force tubing into the Free Flow Clamp). The Z-800 pump will load the tubing into the Free Flow Clamp automatically when the pump door is closed.

iv. Close pump door by pushing down the pump door lever.

v. Open roller clamp. Confirm NO FLOW in drip chamber.




3. Remove the sterile cap on the Fluid tubing; attach tubing to injection cap by pushing and twisting at the same time.

4. Open all clamps.

5. Press the RUN/STOP button to start infusion.



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COMPLETING THE INFUSION


2. Push the RUN/STOP button to stop infusion.


4. Unscrew the administration set from the injection cap.

5. Scrub the injection cap for 15 seconds.

6. Flush with 10mL of Sodium Chloride; followed by Heparin if applicable.

***If Fluids are continuous, may flush with 10mL Sodium Chloride only before reconnecting new bag and

tubing***. REPEAT PREVIOUS STEPS and then press “RESUME INFUSION.”




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Home Medication Mix Supplies needed:

2 Sodium Chloride (Saline) Flush 1 Heparin Flush 6 Alcohol Pads 1 Swab Cap Prescription Medication Vial Diluent Vial [Sterile Water or Sodium Chloride (Saline)] Bag of fluids Syringe and Needle Sharps Container Dial-a-flow tubing (The same tubing is to be used for all doses of the same medication in a 24-hour period) Blue End Caps (for tubing if multiple medication doses given in 24-hour period)

Please WASH HANDS!



RECONSTITUTE MEDICATION AND MIX

Step one: Pop cap off vials of diluent and prescription medication. Clean top of both vials with alcohol swab for 15 seconds.

Step Two: Twist needle onto empty syringe. Pull back ____ mL of air into the syringe and inject air into vial of diluent. Pull back ____ mL of diluent into the syringe.

Step Three: Inject syringe of diluent into the vial of prescription medication. This will turn medication into liquid form. Be sure all powder is dissolved, then pull back ____ mL of the medication.

Step Four: Obtain bag of fluids and clean rubber port with alcohol swab for 15 seconds. Inject needle into rubber port and push all antibiotic into bag of fluids. This will complete steps of reconstituting and mixing medication. Dispose of syringes and needles in Sharps Container.



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PRIME TUBING WITH MEDICATION

Step one: Close the dial on the IV tubing to the “OFF” position

Step two: Pull the rubber seal from the medicine bag.

Step Three: The IV tubing has a spike. Remove the cover from the spike and insert the spike into the bottom of the medicine bag where the seal was removed. Hang the bag on IV pole or door hook through the loop on the top of medicine bag. *Be sure that medication bag is hanging at least 3 feet above patient’s heart, otherwise medication may not infuse. *

Step Four: Fill the drip chamber on the IV tubing with medication. Squeeze the drip chamber with your thumb and index finger until the drip chamber is ½ full.

Step Five: Locate the dial on the tubing and open from the “OFF” position. Fluid will start traveling through the tubing. If flow does not start, squeeze the IV bag. Leave the IV tubing dial open until you see fluid coming through the end of the tubing.

Step Six: Once medicine is coming out of end of tubing close the dial to the “OFF” position and close white clamp on the tubing. You have completed the steps of priming tubing with medication.

MEDICATION ADMINISTRATION & FLUSHING LINE

Step one: Clean end cap of catheter with an alcohol swab for 15 seconds.

Step two: Flush line with Sodium Chloride (Saline) flush.

Step three: Clean with alcohol swab and connect antibiotic, set rate to ___________________ on dial a flow tubing. Open clamp.

Step four: The medication will take ____________________to infuse.

Step five: When the bag is empty, please close clamp and disconnect the tubing from the IV access. The tubing is to be used for all doses of the same medication for a 24-hour period then discarded in the regular trash. If you have three doses per day, you use the same tubing for all three doses of the same medication. *If using tubing for multiple doses in 24 hours, screw Blue End Cap onto end of dial a flow tubing. *

Step six: Clean end of catheter and flush with Sodium Chloride (Saline) Flush.

Step seven: Clean end of catheter and flush with Heparin Flush.





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PEDIATRIC PATIENT TEACHING GUIDE

PICC Flush Supplies needed:

1 Sodium Chloride (Saline) Flush 1 Heparin Flush 2 Alcohol Pads 1 Swab Cap Please WASH HANDS!




Step one: Clean end cap of catheter with an alcohol swab for 15 seconds. Open Clamp.

Step two: Clear air out of Sodium Chloride (Saline) syringe. Flush line by using a pulsing action until syringe is empty.

Step three: Clean end cap of catheter with an alcohol swab for 15 seconds.

Step four: Clear air out of Heparin Syringe. Flush line using a pulsing action until syringe is empty.

Step five: Screw Swab Cap on the end of the PICC line.

Follow this procedure with each lumen of your PICC every 12 hours as directed.



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PEDIATRIC TEACHING GUIDE

Elastomeric Ball Supplies needed:

2 Sodium Chloride (Saline) flush 1 Heparin flush 4 Alcohol Pads 1 Swab Cap


Please WASH HANDS!




Step one: Clean end cap of catheter with an alcohol swab for 15 seconds. Open clamp on PICC.

Step two: Flush line with Sodium Chloride (Saline) flush

Step three: Clean end of catheter with an alcohol swab and connect antibiotic. Open clamp on med ball.

Step four: Check label on bag to determine how long medication will take to infuse.

Step five: At the end of the infusion time, please clamp, disconnect ball and discard in trash.

Step six: Clean end of catheter and flush with Sodium Chloride (Saline) flush.

Step seven: Clean end of catheter and flush with Heparin.

Step eight: Screw new Swab Cap on end of the PICC line.

*If your IV line has more than one lumen, flush “unused” or “other” lumen(s) with one Sodium Chloride (Saline) flush and one Heparin flush every 12 hours as directed on page 29 “PEDIATRIC PATIENT TEACHING GUIDE PICC flush.” *



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PATIENT TEACHING GUIDE

TOTAL PARENTERAL NUTRITION (TPN) on CADD Solis Pump Supplies Needed:

1 or 2 Sodium Chloride (Saline) flush 1 or 2 Heparin flush 1 or 2 Swab Cap 4 Alcohol Pads Tubing for pump Additive Medications if needed Syringes w/needles (if additives are required) Sharps container (if additives are required)

Please WASH HANDS!

Wash surface of work area with Antibacterial wipe or alcohol.



TIPS!

***Before each time you flush or attach TPN to the IV access, scrub the hub for 15 seconds with an alcohol pad using FRICTION. DO NOT FAN OR BLOW ON HUB.

***PRE-FILLED SYRINGES have an air bubble in them. Remove package, evacuate air bubble by loosening cap, holding syringe straight up, pulling back on syringe plunger and then pushing air out of syringe. Re-tighten syringe until ready for use if needed. IF SYRINGE IS CONTAMINATED, DISCARD AND USE ANOTHER.

***Place TPN in refrigerator upon arrival of the delivery and then remove from refrigerator approximately 4 hours before hooking up infusion to allow solution to warm to room temperature. CHECK NAME AND EXPIRATION DATE PRIOR TO USING. ALSO LOOK FOR CLOUDINESS IN CLEAR SOLUTION and OILY LAYERS IN LIPID SOLUTIONS. ALSO CHECK FOR LEAKS AND IF ANY OF THESE THINGS EXIST, DISCARD AND CALL INFUSION SOLUTIONS IMMEDIATELY.

***Use tubing and all other supplies ONLY ONCE



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TROUBLESHOOTING

● Press the “Silence” button when pump is alarming and then press the “Help” button. Follow the screen instructions for clearing the alarm.

● There is an Infusion Solutions nurse on call 24/7. Please dial: 1-888-446-6348 for questions related to the CADD pump.

PREPARING THE TPN BAG 1. Prepare the additives as directed. When removing any cap from the additive, scrub the top of the vial for 15 seconds with an alcohol pad. You may need to attach the needle to the syringe. You will need to choose the correct size syringe for each additive. You will always scrub the injection port to the TPN bag for 15 seconds with an alcohol pad before injecting any additive.

2. There are 2 vials of Multivitamins (Brand name: Infuvite or MVI) – 1 Blue top and 1 White or Yellow top.

i. Use the same needle and syringe to draw up from both vials.

ii. Scrub the injection port on the Fluid bag.

iii. Inject Vitamins into the Fluid bag.

3. If Insulin is ordered to be added to the Fluid bag:

i. Draw up Insulin from vial with ORANGE CAPPED Insulin syringe.

ii. Check Insulin dose with another person.

iii. Scrub injection port on the Fluid bag.

iv. Inject Insulin into the Fluid bag injection port.

*If there are any other medications to be added, follow the same procedures in step 1 plus directions on additive label for correct dose/volume.

4. Mix the solution by holding the bag at both ends and gently rocking it back and forth about 4-5 times. After mixing, the solution should look completely white or yellow if you have added Vitamins. If your solution has streaks or oily layers, DO NOT USE THE BAG AND CALL INFUSION SOLUTIONS IMMEDIATELY!

5. Dispose of all syringes and needles into the Sharps container.

6. Remove the Tubing from the package. Close all clamps. Remove cap from the administration set spike. Remove tab from the TPN bag while keeping both ends sterile. Insert spike into the bag port.



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ATTACHING THE TPN BAG TO THE PUMP 1. Check the right side of the pump: pull lever down on the CADD Solis.

2. Before attaching the clear “passthrough” cassette to the pump, remove the blue clip. The tubing is now clamped closed.

3. Attach the 2 cassette hooks into the hinge pins on the bottom of the pump while sliding the other end up into the rectangle hole.

4. Place the pump upright on a firm surface. Press down so the clear “passthrough” cassette fits tightly against the pump. The clear piece will “click” into place.


PRIMING THE ADMINISTRATION SET 1. Place 4 NEW – “AA” batteries in the top of the pump as shown daily.




5. Press button below the word PRIME. Press only 1 time. PUMP will stop priming at times. Answer the question “Continue priming?” by pressing the button below the words “Yes” or “No”.

6. Make sure the filter is hanging downward during priming. Re-clamp the tubing.

7. Press button under the work “Back” twice to get back to the main screen.

STARTING THE INFUSION 1. Scrub the hub on the injection cap for 15 seconds. Flush with 10mL Sodium Chloride.


3. Remove the sterile cap on the TPN tubing; attach tubing to injection cap by pushing and twisting at the same time. Open all clamps.




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COMPLETING THE INFUSION When infusion is complete, the screen will turn red with a Stop Sign and a Hand on the screen. At this time, you may disconnect. If the nurse is assisting with disconnect and he/she has not arrived at this time, the pump will convert to a “Keep Vein Open” rate automatically and continue pumping until all the solution is emptied from the bag. The pump will continue to have the Stop sign and Hand on the screen while remaining red.


2. PUSH the START/STOP button to Power down. Press button below the word “YES”.


4. Unscrew the administration set from the injection cap. Remove the clear “passthrough” cassette from the pump by lowering the lever and then pushing downward until the cassette releases.

5. Scrub the injection cap for 15 seconds. Flush with 20mL of Sodium Chloride (2 syringes back to back); followed by Heparin if applicable.

6. If you are not receiving a continuous 24-hour TPN, screw a new Swab Cap on the end of catheter.

7. Remove batteries from pump.




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ENTERAL THERAPY OVERVIEW

Why am I receiving Enteral Nutrition Therapy?

Enteral Nutrition (EN), also known as Tube Feeding (TF), is required for patients who have an illness resulting in the inability to meet their daily nutritional needs from food and/or oral nutrition supplements. Enteral Nutrition consists of a nutritionally complete liquid food mixture; containing fats, carbohydrates, protein, water, vitamins, & minerals, delivered directly into the patient’s stomach or small intestine through a feeding tube. EN can either be a short or long-term therapy that assists patients with meeting their daily calorie, nutrient, and fluid requirements needed to improve or maintain their nutrition status. A gastrostomy tube is placed into the stomach, and a jejunostomy tube is placed into the small bowel.

Feeding Methods

There are 3 different ways that your enteral feedings can be infused, and your TF regimen form will show the method that your Physician ordered.

1. Syringe (Bolus) – amount of formula, usually > 237 mL is administered using an enteral syringe. This method should take about 10-20 minutes. If formula is given too quickly, abdominal cramping, diarrhea, nausea, and/or vomiting could result. Follow your water flush instructions on your personal tube feeding regimen. This method will not be used if you have a jejunostomy.

2. Gravity (Intermittent) – this method usually consists of giving approximately 250-500 mL of formula over approximately 30-60 minutes. Feeding set hangs about 2 feet above your feeding tube and gravity feeds the formula through the tube into your gastrostomy tube. Roller clamp controls the rate that feeding is delivered.

3. Continuous (Pump) – this is the recommended method if you have a jejunostomy. Every hour, the pump will infuse a small amount of liquid over a period of 16-24 hours. This is a slower method than the first two methods and is tolerated well by those patients who don’t tolerate higher administration rates.



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Gravity Enteral Nutrition 1. Always begin by washing your hands. Remove end cap or stopcock from feeding tube

and insert 60mL syringe. Check residual. If residual is less than 250mL, return residual contents and flush feeding tube with 30mL water. Replace end cap or stopcock on feeding tube. (If residual is greater than 250mL, hold the feeding. Recheck residual in 4 hours, if less than 250mL, continue with feeding as ordered.)

2. Hang the feeding set (bag with tubing) on the door hook or IV pole provided in your delivery. You want the feeding set to be 2 – 3 feet above the shoulder. Make sure the roller clamp is closed.

3. Clean the top of the formula container with a damp, clean, cloth or paper towel.

4. Open the cap to the feeding bag and pour the amount of formula you are to receive into the bag. Close the cap.

5. Open the roller clamp and allow the formula to flow through the tubing to the tip of the tube, then close the roller clamp. This is called priming the tubing.

6. Remove the end cap or stopcock from the feeding tube and insert tip of tubing. Unclamp the roller clamp and allow the formula to enter the feeding tube. When the feeding is complete, close the roller clamp. Remove the cap from the bag of the feeding set and pour in the amount of water ordered for post feeding flushes. Close the cap on the bag of the feeding set. Open the roller clamp and allow the water to flow through the feeding tube until empty. This will flush the feeding tube. Remove the feeding set from the feeding tube. Replace the end cap or the stopcock on the feeding tube.

7. Thoroughly rinse the feeding set with warm water, air dry, and close cap on the feeding set until the next feeding. Keep the feeding set in the refrigerator to minimize the chance of bacterial growth.

********Change the Feeding Set every 24 hours********



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Bolus/Syringe Fed Enteral Nutrition 1. Always begin by washing your hands. Clean the top of the formula container with a

damp, clean cloth or paper towel.

2. Remove the end cap or stopcock from the feeding tube and insert 60mL syringe. Check for residual. If residual is less than 250mL, return residual contents and flush feeding tube with 30mL water. (If residual is greater than 250mL, hold the feeding. Recheck residual in 4 hours, if less than 250mL, continue with feeding as ordered.)

3. With the syringe remaining in feeding tube, pour the formula into syringe. The speed of the flow depends on the height of the syringe. If the feeding is flowing too fast and the patient is not tolerating it well, you can lower the syringe towards the stomach to slow the flow of the feeding or slightly crimp the tube to slow the flow if needed. It should take approximately 15-30 minutes to complete 1 can of formula.

4. Upon completion of bolus feeding, with the syringe remaining in place, flush the tube with the amount of water ordered for post feeding flushing. Remove the syringe.

5. Wash the syringe with warm water and soap, allow to air dry. Place syringe back into 500mL basin for storage.



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Enteral Nutrition Delivered via Infinity Pump 1. Always begin by washing your hands. Remove end cap or stopcock from the feeding

tube and check for residual. If residual is less than 250mL, return contents and flush the feeding tube with 30mL water. Replace end cap or stopcock on feeding tube. (If residual is greater than 250mL, hold the feeding. Recheck residual in 4 hours, if less than 250mL, continue with feeding as ordered.)

2. Open feeding set and close roller clamp, open the cap on the bag of the feeding set and pour the formula into the bag. Close the cap on the bag of the feeding set. Hang the bag of the feeding set on the door hook or IV pole that was provided with your delivery.

3. Open the door on the pump and load the pump with the tubing from left to right. Place the loop of the tubing around the black circular wheel and stretch it slightly to snap in place. Close the pump door.

4. Turn the pump on, (upon delivery of the pump, it will be programmed with the ordered dose and rate), open the roller clamp and remove the cap on the tip of the tubing. Press and hold the prime button. Continue to hold the prime button until the formula has reached the tip of the tubing. Release the prime button.

5. Remove the end cap or stopcock from the feeding tube and insert the tubing from the feeding set. Push the Run/Pause button on the pump and it will begin running. Display will show programmed rate and the arcs around the run symbol will rotate.

6. When the feeding is complete, the display will read “Dose Done.” At this time, turn the pump off and remove the tip of the feeding set tubing from the feeding tube and insert the 60mL syringe into the feeding tube. Flush the feeding tube with the ordered amount of water for the post feeding flush. Place the end cap or stopcock on the feeding tube when flushing is complete.

7. Dispose of feeding set and wash the syringe with soap and warm water and allow to air dry. Store syringe in 500mL basin once dry.



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Enteral Nutrition Delivered via EntraFlo H20 pump 1. Always begin by washing your hands. Remove end cap or stopcock from the feeding

tube and check for residual. If residual is less than 250 mL, return contents and flush the feeding tube with 30 mL of water. Replace end cap or stopcock on feeding tube. (If residual is greater than 250 mL, hold the feeding. Recheck residual in 4 hours, if less than 250 mL, continue with feeding as ordered.)

2. Open feeding set and close both clamps on delivery set prior to setup. Prepare and hang pump set from the IV pole 6 inches above pump.

3. Open delivery set security doors by pulling the latch on top of each door.

4. Insert water drip chamber into water side drip chamber bracket, and feeding drip chamber into feeding side drip chamber bracket.

5. Carefully stretch water set silicone tubing around rotor. Insert pump adapter into bridge. Place tubing into tubing guide, close and latch delivery set security door.

6. Repeat step 5 with feeding side delivery set.

7. Press “ON”- alarm sounds briefly and displays ‘8’8’8’8. The pump has memory and displays previous settings, and returns to flashing Feeding rate on the display panel.

8. Open both clamps on the delivery set. Remove the Luer adapter cap from the delivery set, and place the cap in the Luer adapter cap holder available on the pump.

9. Press PRIME for automatic priming of the delivery set. The pump displays a series of P’s during the prime cycle and the rotor begins to turn. Feeding is primed first, then water through the delivery line. The prime cycle completes in approximately 3 minutes. An audible alarm sounds with the priming is complete, the pump goes into pause mode, and the feeding rate flashes.

10. Remove the end cap or stopcock from the feeding tube and insert the tubing from the feeding set.

11. Press the Run/Pause button to being enteral feeding. The pump primarily displays the feeding rate. It briefly displays the feeding volume delivered every 7 seconds.

12. When feeding is complete, the display will read “doSE dEL,” and an audible alarm will sound. At this time, turn the pump off using the off button and remove the tip of the feeding set tubing from the feeding tube.

13. Place the end cap or stopcock on the feeding tube.

14. Dispose of feeding set.



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Enteral Nutrition Delivered via Kangaroo Joey Pump 1. Always begin by washing your hands. Fill flush bag with designated amount of sterile

water.

2. Fill feed bag with prescribed amount of formula. Hang bag on pole.

3. Turn the pump on by pressing the soft power key in the lower right-hand side of the pump. The pump will do a quick self-test

4. Open blue door enclosing pump loading area.

5. To load pump set grasp finger tab on valve and insert into front pocket. Grasp black ring retainer and wrap tubing around rotator wheel. Pull up on retainer and insert into back pocket. Avoid overstretching the silicone tube. Push finger tab to right to ensure that valve is fully seated in the pocket.

6. Close blue door. (You should be able to see the finger tab clearly through the slot in the blue door.)

7. Make sure the bags are suspended so that the top of the starting volume of formula is 6 inches above the pump.

8. To automatically prime the pump, press “Prime Pump” then “Auto Prime” this will prime both lines.

9. Once the pump has primed, connect the tubing to the feeding tube and press “Run”. The screen will display running.

10. To stop the pump, press “Hold” or if you need to turn the pump off press and hold the power key.



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Enteral Nutrition Tube Site Care

****Clean your tube site every 24 hours as directed below****

1. You will need soap, cotton tipped applicator, warm water, damp clean cloth, dressing and adhesive tape.

2. Wash your hands before you begin.

3. Thoroughly and gently clean around the tube site. Start at the tube site and work outward in circles (this cleans bacteria away from the tube site), do not pull on the tube while cleaning. If your tube has a skin disk, there should be ¼” space between the disk and the skin to avoid skin breakdown.

4. Rinse the area by wiping with damp, clean cloth to remove any residual soap. Allow to dry completely.

5. Using the dressing split sponge supplied in your delivery, place sponge around the feeding tube. If needed, place a small piece of tape on the sponge to hold it in place. Use caution when removing the sponge so that you do not damage the skin.

6. Change the dressing as needed throughout the day if it should become saturated.

*****A small amount of drainage around the tube is normal. If a crusty drainage accumulates at your tube site it can be easily removed with ½ hydrogen peroxide. (½ water and ½ hydrogen peroxide) and a cotton tipped applicator. DO NOT use full strength hydrogen peroxide and do not use for daily cleaning.



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COMPANY OVERVIEW CRITERIA FOR ADMISSION

Admission to this agency can only be made under the direction of a physician, based upon the patient’s identified care needs and the type of services required that we can provide directly or through coordination with other organizations.

SERVICES

This company can provide a service or a combination of services in your home all under the direction of a physician. Working with your doctor, our qualified staff will plan, coordinate and provide care tailored to your needs. Our services include:

Home Infusion Therapy-Antibiotics, Pain Management, Chemotherapy, Hydration, Parental Nutrition, Enteral Nutrition and a variety of other IV medications.

Registered and Licensed Practical Nurses for consultation and coordination of services.

Registered Pharmacist for preparing medication and monitoring care.

Reimbursement representative for handling your billing and insurance needs.

___________________________________________________________________

HOURS OF OPERATION

Office Hours: Our business hours are Monday through Friday from 8:30 AM to 5:30 PM., except during company holidays.

On-Call/After Hours Coverage: Coverage is available 24 hours a day, 7 days a week through an answering service and on-call staffing after normal working hours, weekends and holidays. A Pharmacist and a nurse are on-call 24 hours a day, 7 days a week.



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PATIENT’S RIGHTS AND RESPONSIBILITIES Each Patient Has the Right To:

▪ Be treated with dignity and respect without regard to race, color, creed, sex, age, national or ethnic origin, diagnosis, or source of payment.

▪ Be provided with information regarding ownership, available services and charges. ▪ Be informed about his/her illness and treatment, when and how services will be

provided, the name and function of any person and agency providing care and service, and the name of person responsible for coordination of care.

▪ Make informed decision about his/her care and actively participate in the planning level of self-care and wellness.

▪ Be instructed in his/her care/therapy in order to reach the highest level of self-care and wellness.

▪ Continuity of care and service provided by personnel who are qualified through education and experience to perform the service for which they are responsible.

▪ Participate in experimental treatment and research with voluntary, informed consent documented.

▪ Refuse treatment, within the confines of the law, after being fully informed of and understanding the consequences of such action.

▪ Confidentiality and privacy in treatment and care, including confidential treatment of patient records, and to refuse their release to any individual outside, except in the care of transfer to another health facility or as required by law or third-party contract.

▪ Voice complaint and grievance and be informed of procedure for registering complaints without reprisal, coercion, discrimination or unreasonable interruption of services.

▪ Receive prompt response to all reasonable interruption of services. ▪ Have pain managed.

Patient is Responsible:

▪ For providing accurate and complete information regarding his/her medical history. ▪ For agreeing to a schedule of services and reporting any cancellation of scheduled

appointments. ▪ For participating in the development and updating of a plan of care. ▪ For communicating whether he/she clearly understands the course of treatment and

plan of care. ▪ For following the plan of care and clinical condition. ▪ For reporting problems, unexpected changes in physical condition, rehospitalizations,

concerns or complaints. ▪ For accepting responsibility for his/her actions if refusing treatment. ▪ For fulfilling financial obligations for services. ▪ For respecting the rights of home care givers.



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NOTICE OF PRIVACY PRACTICES Effective 4/17/2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS CAREFULLY. Acquisition, access, use or disclosure of protected health information that is not permitted by the Privacy Rule which compromises the security or privacy of that information is presumed to be a breach. You will be notified if a breach exists incidentally from Infusion Solutions. If you have any questions, please contact our Privacy Office at the address or phone number at the bottom of this notice.

There are 3 exceptions to this definition of a breach:

1. Any unintentional acquisition, access or use of protected health information by a workforce member or individual acting under the authority of Infusion Solutions or Business Associate if such access or use was made in good faith and within the scope of authority and does not result in further unauthorized use or disclosure.

2. Any inadvertent disclosure by a person who is authorized to access protected health information by Infusion Solutions or Business Associate to another person authorized to access protected health information at Infusion Solutions or the same business associate and the information is not further used or disclosed in an impermissible manner.

3. A disclosure of protected health information where Infusion Solutions or business associate has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonably have been able to retain such information.

Who will follow this notice?

Infusion Solutions provides health care to our patients in partnership with physicians and other professionals and organizations. The information privacy practices in this notice will be followed by:

• All employed associates, staff or volunteers of our organization, including staff at our parent organizations, with which we may share information.

• All departments of our organization, including nursing, billing, pharmacy, delivery and management.

• Any Business Associate with which we share health information. A Business Associate is defined as an entity that maintains, creates, receives or transmits protected health information on behalf of Infusion Solutions. A Business Associate does not access protected health information. A Business Associate may offer a personal health record.



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A Business Associate may have subcontractors who must follow this notice as well and does not actually view protected health information. Types of Business Associates are: Health information organizations or entities that provide data transmission services with respect which include companies that maintain protected health information for Infusion Solutions but do not actually view the protected health information or only do so on a random or infrequent basis such as a storage company or cloud-computing company. A subcontractor is described as persons that perform functions for or provide services to a Business Associate involving protected health information for purposes of the Business Associate fulfilling its obligations to Infusion Solutions with which it has contracted.

• Any other health organization involved in your care.

• Entities that do not follow under a Business Associate would be UPS, USPS, FedEx and other courier services and their electronic equivalents such as internet service providers, banking and financial institutions with respect to payment processing activities, health care plan product or other insurance such as professional liability insurance from an insurer. If bank or financial institution provides activities which go beyond the exempted activities, such as performing accounts receivable functions on behalf of Infusion Solutions, then this entity would be considered a Business Associate.

Our pledge to you

We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements, this notice applies to all of the records of your care that we maintain, whether created by facility staff or your personal doctor. Your personal doctor may have different policies or notice regarding the doctors’ use and disclosure of your medical information created in the doctor’s office. We are required by law to:

• Keep medical information about you private.

• Give you this notice of our legal duties and privacy practices with respect to medical information about you.

• Follow the terms of the notice that is currently in effect.

Changes to this Notice

We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the changes occur. You will be notified in writing of any significant changes in our policies. You can also receive a copy of the current notice at any



46

time. You may also request a copy of the most current penalties related to HIPAA violation at any time, this effective date is listed just below the title.

How we may use and disclose medical information about you.

• Treatments: To coordinate the treatment, medications and services provided to you. We may contact you in regards to medications, equipment, supplies, compliance, deliveries, product recalls, phone assessments, and other pharmacy recommendations for treatment, and nursing/pharmacy consultation. We may also contact you regarding possible treatment options, alternatives, health related benefits or services that may be of interest to you.

• Payment: We may contact your insurer, pharmacy benefit manger or other health payer to coordinate coverage, benefits, copays, and payments for the therapies provided. The information on the bill will have identifying information about you as well as therapies prescribed to you.

• Healthcare Operations: We may need to use your health information in conjunction with other healthcare providers such as physicians, home health agencies, other departments within our parent organizations, labs, and other pharmacies to coordinate proper care for you. We may also use your health information for administrative, performance improvement activities and to monitor the performance of staff providing treatment to you. We may disclose your health information to Business Associates or their subcontractors if they need this information to provide services to you. The Business Associate will be required to comply and are legally accountable to the US Department of Health and Human Services to comply with privacy practices.

We may also use and disclose medical information about you to:

• Individuals involved in your care or payment of your care. This includes notifying or assisting in notifying a family member or other persons responsible for your care, regarding your location and general condition.

• FDA-information related to adverse drug events for surveillance information to enable drug recalls, repairs and replacement for equipment.

• Worker’s compensation or other similar programs established by law.

• Law Enforcement in response to a subpoena or court order.

• Public Health to comply with law in regards to preventing or controlling diseases, injuries or disabilities.

• Health oversight activities such as audits, inspections, credentialing, and investigations. This is to comply with licensure, government programs and civil rights laws.



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• Respond to Judicial and Administrative orders regarding a lawsuit or dispute.

• Research approved by an intuitional review board or privacy board ensuring your information privacy.

• Coroners/Medical Examiners/Funeral Directors; Organ and Tissue Organizations. This is for identification purposes so these entities can fulfill their duties.

• A Correction Institution if you become an inmate.

• Prevent a serious threat to your health and safety.

• The armed forces if required by military command authorities.

• National Security/Intelligence Agencies/Protective Services for the President and Others. This is for intelligence, counterintelligence, protection to the President and other national security activities authorized by law.

• To a government authority in response to abuse or neglect allegations. We will disclose information allowed by law if we believe it is necessary to prevent serious harm to you or someone else.

Other uses of medical information

• In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing medical information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision.

Your rights regarding medical information about you

• In most cases, you have the right to look at or get a copy of medical information that we may use to make decision about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.

• If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the records, by submitting a request in writing that provide your reason for requesting the amendment. We could deny your request to amend a record if the information was not created by us; if it is not part of the medical information obtained by us; or if we determine that the record is accurate. You may appeal, in writing, a decision by us not to amend a record.

• You have the right to a list of those instances where we have disclosed medical information about you, other than for treatment, payment health care operations or



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where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 17th, 2013. You may receive the list in paper or electronic form. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you prior before incurring any cost.

• You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you.

• You may request, in writing, that we not use or disclose medical information about you for treatment, payment or other healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request but we are not legally required to accept it. We will inform you of our decision on your request. All written requests or appeals should be submitted to our Privacy Officer.

• You have the right to restrict disclosures of your health information to a health care plan for which you have pain out of pocket in full.

Use and Disclosure of Protected Health Information for Marketing Purposes

If Infusion Solutions received financial remuneration in exchange for making a communication about a health-related product or service, the communication is considered marketing and Infusion Solutions must obtain the individual’s valid authorization which includes a disclosure that Infusion Solutions or Business Associate is receiving financial remuneration from a third party for making the communication-prior to actually making the communication. The following are excluded from the definition of marketing:

• Communications for treatment or health care operations activities that are made face-to-face, even if Infusion Solutions received financial remuneration for making the communication or the communication consists of a promotional gift of nominal value provided by Infusion Solutions.

• Refill reminders or other communications about drug or biologic that is currently prescribed for the individual, provided that any financial remuneration Infusion Solutions receives for making such a communication is reasonably relates to Infusion Solutions cost of making the communication.

• Communications promoting health in general that do not promote a product or services from a particular provider.



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• Communications about government and government-sponsored programs.

Research Activities-Non-applicable

Fundraising Activities-Non-applicable

Disclosure of Immunization Records to Schools-Non-applicable

Prohibition on the Sale of Protected Health Information

Sale is described as a disclosure of protected health information by Infusion Solutions or Business Associate where there is direct or indirect receipt of payment from or on behalf of the recipient of the protected health information in exchange for the protected health information. A sale of protected health information is not limited to only those instances where there is a transfer of ownership of the protected health information, but also includes payments for access, license, or lease agreements related to protected health information. The payment must be related to the protected health information rather than the service involving access to this information.

i. Exceptions include:

• For public health activities.

• For treatment of the individual and payment.

• For the sale, transfer, merger or consolidation of all or part of Infusion Solutions and for related due diligence purposes if the recipient of the protected health information is or will become a covered entity following the sale, transfer or merger.

• Research purposes.

• Record requests for preparing and transmitting records from a Business Associate or its subcontractor or directly by Infusion Solutions. Fees must be reasonable, cost-based to cover the cost of preparing and transmitting data.

• As required by law.

• For providing an individual with access to his or her protected health information, including the provision of an accounting of disclosures.

As it applies to the aforementioned exceptions, cost-based remuneration or payment includes both direct and indirect costs (including labor, materials, and supplies for generating, storing, retrieving, and transmitting protected health information), labor and supplies to ensure the protected health information is disclosed in a permissible manner, and overhead costs.



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Use and Disclosure of a Decedent’s Protected Health Information

Protected health information may be used or disclosed if an individual has been deceased more than 50 years for any purpose unless state or other laws provide otherwise. Information may be made to family members and others who were involved in an individual’s care, unless doing so is inconsistent with any prior expressed wishes or preferences of the individual.

Complaints

• If you are concerned that your privacy rights may have been violated or you disagree with a decision we made about access to your records, you may contact the Privacy Officer (listed below).

• Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights (listed below).

• Under no circumstances will you be penalized or retaliated against for filing a complaint.

Privacy Officer: U.S. Department of Health

Justin Blake Gillum & Human Services

1557 Winchester Ave Office of Civil Rights

Ashland, KY 41101 200 Independence Avenue, SW

1-606-325-1115 Washington, D.C. 20201

1-888-446-6348 1-202-619-0257

[email protected] 1-877-696-6775

mailto:[email protected]



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INFECTION CONTROL AT HOME (IV THERAPY) Cleanliness and good hygiene help prevent infection. Contaminated materials: such as bandages, dressings or surgical gloves can spread infection and harm the environment. If not disposed of properly, these items can injure trash handlers, family members and others who could come in contact with them.

Certain illnesses and treatments (i.e., chemotherapy, dialysis, AIDS, diabetes, burns) can make people more susceptible to infection. Your nurse will instruct you on the use of protective clothing if they are necessary.

Notify your physician and/or home care staff if you develop any of the following signs and symptoms of infection:

Pain/tenderness/redness or swelling of body part Fever or chills

Inflamed skin/rash/sores/ulcers Sore throat/cough

Painful urination Increased fatigue/weakness

Confusion Pus (green/yellow drainage)

Nausea/vomiting/diarrhea

YOU CAN HELP CONTROL INFECTION BY FOLLOWING THESE GUIDELINES

WASH YOUR HANDS

Wash your hands before and after giving any care to the patient (even if wearing gloves), before handling or eating foods, and after using the toilet, changing a diaper, handling soiled linens, touching pets, coughing, sneezing or blowing nose. Hand washing needs to be done frequently and correctly. Remove jewelry: use warm water and soap (Liquid soap is best), hold your hands down so water flows away from your arms, scrub for at least 20-30 seconds for unsoiled hands and 40-60 seconds for soiled hands using friction, making sure you clean under your nails, between your fingers. Dry your hands with a clean paper towel, and use a new paper towel to turn off the faucet. If using an alcohol-based hand sanitizer, rub hands until dry. Do not use hand sanitizer if hands are soiled.

Washing your hands is the single most important step in controlling the spread of infection.



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DISPOSABLE ITEMS & EQUIPMENT Items which are not thrown away including: soiled laundry, dishes, thermometers, commode, walkers, wheelchairs, bath seat, suction machines, infusion pumps, oxygen equipment,

mattresses, etc.

Equipment utilized by the patient will be cleaned immediately after each use. Small items should be washed with hot soapy water, rinsed and dried with clean towels. Household cleaners such as disinfectant, germicidal liquids or diluted bleach may be used to wipe off equipment. Follow the equipment cleaning instructions and ask your home care staff for clarification. Infusion pumps will be cleaned by the infusion company upon return but can be cleaned with an all-purpose cleaner if it becomes dirty during the course of therapy.

Soiled laundry should be washed apart from other household laundry in hot soapy water. Handle these items as little as possible to avoid spreading germs. Household liquid bleach should be added if viral contamination is present (a 1-part bleach to 10 parts water solution is recommended).

Thermometers should be wiped with alcohol before and after each use unless protective covers are used. Store in a clean, dry place.

Liquids may be discarded in the toilet and the container cleaned with hot, soapy water, rinsed with boiling water and allowed to dry.

SHARP OBJECTS Items which are sharp may include: needles, lancets, scissors, knives, staples, glass tubes or bottles, IV catheters, razorblades, disposable razors, etc.

Place used “sharps” directly into a clean rigid container with a screw-on or tightly secure lid. Use a hard-plastic container such as a red biohazard bin provided by Home Health or the infusion company or a heavy-duty laundry detergent bottle. May also use a coffee can. Before discarding, reinforce the lid with heavy-duty tape such as duct tape.

Never overfill the containers or recap needles once used. DO NOT USE GLASS or CLEAR PLASTIC CONTAINERS and NEVER PUT “SHARPS” IN CONTAINERS THAT WILL BE RECYCLED OR RETURNED TO A STORE. Seal the container with tape and place in the trash can or dispose of according to area regulations.

For needles and catheters used for your infusion therapy, we will provide a red sharps container for disposal. NEVER OVERFILL THE CONTAINER OR RECAP NEEDLES ONCE USED. When this container becomes ¾ full notify the infusion company for delivery of a new one and dispose of used biohazard by locking lid and reinforcing with heavy-duty tape and dispose of in your waste receptacle.



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SPILLS IN THE HOME Blood/body fluid spills are cleaned by putting on gloves and wiping fluid with paper towels. Use a cleaning solution of household bleach and water (1 cup of bleach to 10 cups of water) to wipe the area again. Double bag used paper towels and dispose of in the trash.

Chemotherapeutic agent spills should be cleaned up using an approved chemotherapy spill kit. For chemotherapy patients, a spill kit will be provided by the infusion company and will remain in the home at all times. If chemotherapy spill occurs, please call your nurse or the infusion company immediately for further instructions. Your chemotherapy spill kit will have step by step instructions for use.

SANITATION Keep perishable foods refrigerated and periodically check for freshness. Dispose of household trash in a covered waste receptacle outside the home. Cleanliness and good hygiene help prevent infection.

TIPS ON MEDICAL EQUIPMENT SAFETY Note: Your home healthcare nurse will instruct you and/or your caregiver on the proper use and safety precautions regarding your medical equipment.

Careful examination: Any type of medical equipment should be examined prior to use. Check to make sure connections, cords, wires or screws are tight. Make sure electrical cords or connections don’t have obvious damage such as tears. Make sure equipment is not dented or punctured in any way.

Electrical Safety: For any type of medical device or piece of equipment that needs to be plugged in, check to make sure cords and plugs are in good condition. Plug equipment into grounded outlets and make sure all cords are not exposed to excessive heat or moisture. Keep cords tucked away to prevent falls as well.

Operating Proficiency: Learn how to correctly operate the device. Read the patient instruction booklet provided to you upon admission. Ask for guidance and further instruction from your home healthcare nurse. Know the function of the medical device and be able to recognize whether or not it’s operating correctly, and know what to do if the device fails. Any type of medical device must never be operated by someone who has not been adequately trained in its use.

Determine Risks and Hazards for Use: Be prepared. Review the “Caution” section of your pump booklet. Examine the device and surroundings for potential hazards. Ask yourself the following questions: Are there any obstructions to pushing the IV pole/stationary pump from room to room? Are there throw rugs that need to be removed? Are the electrical outlets



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accessible and in good working condition? Are my outlets 3 prong and if not, do I have an adapter? Has the nurse been adequately trained in the use of the medical equipment? Is the IV pole sturdy with top and bottom screwed tightly together? Is the pump securely attached to the IV pole? Is the bottom of the IV pole screwed tightly together? Does the tubing fit snugly into the pump? Is the cartridge of medication cracked or leaking? Are the screens to the pump clearly visible? Are the lighting and alert lights working properly?

Note: Always feel comfortable in asking questions. Never operate any kind of medical equipment unless you feel comfortable and confident. Infusion Solutions is available as backup to the home healthcare nurses.

HOW TO PLACE A PRESCRIPTION ORDER It is our policy at Infusion Solutions to help you place a prescription order. Your prescriber may contact us at 606-325-1115 for Ashland, KY, office or 304-341-0030 for Charleston, WV, office to submit a verbal order. We also accept prescriber faxes or electronic prescriptions.

HOW TO CHECK ON A PRESCRIPTION ORDER You may contact us at (606) 325-1115 for Ashland, KY, office or (304) 341-0030 for Charleston, WV, office at any time to check on a prescription order.

HOW TO HANDLE ADVERSE REACTIONS An adverse reaction is defined as any unpredictable, unintended, undesirable, and unexpected biological response that a patient may have to medications. Below is a list of the some of the possible adverse reactions that may be experienced when starting a new medication:

• Headache, tremors, dizziness; muscle spasms, confusion;

• Nausea, vomiting, diarrhea;

• Skin rash or flushing;

• Hypotension (low blood pressure), Hypertension (high blood pressure), arrhythmia (irregular heart beat), tachycardia (high heart rate), or bradycardia (low heart rate);

• Shortness of breath, dyspnea (difficulty in breathing), or respiratory depression (slowed breathing).

If an adverse drug reaction is reported to our clinical staff, the pharmacist shall do a complete clinical assessment with the patient and based on his/her clinical judgment will formulate a plan of action. This plan of action could include counseling you on common preventative measures if a known and manageable adverse reaction is reported or contacting your physician to obtain instructions that may involve discontinuing the medication, or modifying the dose.



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HOW TO ACCESS MEDICATIONS IN CASE OF AN EMERGENCY OR DISASTER Infusion Solutions has an emergency plan to provide prescriptions to our customers in case of emergency or disaster. Infusion Solutions will make reasonable attempts to contact each patient following a disaster to assess their needs. Infusion Solutions will prioritize patients based upon the urgency of the need for service. The following local services may be contacted by the patient if needed:

• Local pharmacies near the patient’s address

• The local hospital(s) near the patient’s address

• The local EMS office (911 Services)

• FEMA

HOW TO HANDLE MEDICATION AND PRODUCT RECALLS Upon receiving notification of a medication or product recall, Infusion Solutions will take the following steps:

1. Review inventory and records for the disposition of the recalled item.

2. Contact the patient/caregiver by telephone as appropriate to arrange for exchange of products. If Infusion Solutions cannot reach the patient or caregiver, the following notification methods shall be used:

• Contact you by phone or certified letter

• Contact your emergency contact friend or relative

• Contact your physician’s office

3. Remove the items(s) from service and provide the patient with instructions.

4. Follow the steps recommended by the manufacturer and/or FDA.

HOW TO DISPOSE OF MEDICATIONS Follow any specific disposal instructions on the drug label or patient information that accompanies the medication. Do not flush prescription drugs down the toilet unless this information specifically instructs you to do so.

Take advantage of community drug take-back programs that allow the public to bring unused drugs to a central location for proper disposal. Call your city or county government's household trash and recycling service to see if a take-back program is available in your community.

If no instructions are given on the drug label and no take-back program is available in your area, throw the drugs in the household trash, but first:



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• Take them out of their original containers and mix them with an undesirable substance, such as used coffee grounds or kitty litter. The medication will be less appealing to children and pets, and unrecognizable to people who may intentionally go through your trash.

• Put them in a sealable bag, empty can, or other container to prevent the medication from leaking or breaking out of a garbage bag.

Additional tips:

• Before throwing out a medicine container, scratch out all identifying information on the prescription label to make it unreadable. This will help protect your identity and the privacy of your personal health information.

• Do not give medications to friends. Doctors prescribe drugs based on a person's specific symptoms and medical history. A drug that works for you could be dangerous for someone else.

• When in doubt about proper disposal, talk to your pharmacist.

• The same disposal methods for prescription drugs could apply to over-the-counter drugs as well.

PROTOCOL FOR RESOLVING PATIENT COMPLAINTS The patient has the right to freely voice grievances and complaints regarding treatment or care without being subject to coercion, discrimination, fear of reprisal, or unreasonable interruption of care, treatment and services. Contact the Clinical Coordinator by telephone, toll-free, 1-888-446-6348 or in writing at the following address: 1557 Winchester Ave., Ashland, KY, 41101.

All complaints will be handled in a professional manner. All logged complaints will be addressed within 5 calendar days via oral, telephone, email, fax or letter format after the receipt of the complaint. Infusion Solutions will notify the patient or legal representative regarding results of its investigation within 14 days.

Infusion Solutions will maintain documentation of all complaints received, copies of investigations and responses to the patient or legal representative.

Patients or their legal representative may also contact the following organizations with grievances or complaints:

Kentucky Board of Pharmacy 1-502-564-7910

West Virginia Board of Pharmacy 1-304-558-0558

Accreditation Commission for HealthCare 1-855-937-2242



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MEDICARE DMEPOS SUPPLIER STANDARDS Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).

1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.

2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.

3. An authorized individual (one whose signature is binding) must sign the application for billing privileges.

4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.

5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.

6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.

7. A supplier must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.

8. A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards.

9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll-free number available through directory assistance. The exclusive use of a beeper, answering machine or cell phone is prohibited.

10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.

11. A supplier is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition, see 42 CFR 424.57 (c) (11).

12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery and beneficiary instruction.

13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.

14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries.

15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.

16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.

17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.

18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.

19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.

20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.

21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.

22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals).

23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.

24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.

25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.

26. Must meet the surety bond requirements specified in 42 CFR 424.57(d).

27. Must obtain oxygen from a state-licensed oxygen supplier.

28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR 424.516(f).

29. The supplier is prohibited from sharing a practice location with any other Medicare suppliers or providers.

30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848(j)(3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.



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CADD SOLIS INFUSION PUMP LIMITED WARRANTY Smith’s Medical MD, Inc. (the "Manufacturer") warrants to the Original Purchaser that the CADD®-Solis Ambulatory Infusion Pump ("Pump"), not including accessories, shall be free from defects in materials and workmanship under normal use, if used in accordance with this Operator's Manual, for a period of two years from the actual date of sale to the Original Purchaser. THERE ARE NO OTHER WARRANTIES. This warranty does not cover normal wear and tear and maintenance items, and specifically excludes batteries, administration sets, extension sets or any other accessory items or equipment used with the Pump. Subject to the conditions of and upon compliance with this Limited Warranty, the Manufacturer will repair or replace at its option without charge (except for a minimal charge for postage and handling) any Pump (not including accessories)which is defective if a claim is made during such two-year period.

The following conditions, procedures, and limitations apply to the Manufacturer's obligation under this warranty:

A. Parties Covered by this Warranty: This warranty extends only to the Original Purchaser of the Pump. This warranty does not extend to subsequent purchasers. The Original Purchaser may be a patient, medical personnel, a hospital, or institution which purchases the Pump for treatment of patients. The Original Purchaser should retain the invoice or sales receipt as proof as to the actual date of purchase.

B. Warranty Performance Procedure: Notice of the claimed defect must be made in writing or by telephone to the Manufacturer as follows: Customer Service Department, Smiths Medical MD, Inc., 1265 Grey Fox Road, St. Paul, MN 55112, (800) 426-2448 (USA, Canada) or Smiths Medical International Ltd. WD24 4LG, UK, +44 (0)1923 246434.Notice to the Manufacturer must include date of purchase, model and serial number, and a description of the claimed defect in sufficient detail to allow the Manufacturer to determine and facilitate any repairs which may be necessary. AUTHORIZATION MUST BE OBTAINED PRIOR TO RETURNING THE PUMP. If authorized, the Pump must be properly and carefully packaged and returned to the Manufacturer, postage prepaid. Any loss or damage during shipment is at the risk of the sender.

C. Conditions of Warranty: The warranty is void if the Pump has been 1) repaired by someone other than the Manufacturer or its authorized agent; 2) altered so that its stability or reliability is affected; 3) misused; or, 4) damaged by negligence or accident. Misuse includes, but is not limited to, use not in compliance with the Operator's Manual or use with nonapproved accessories. The Pump is a sealed unit, and the fact that the seal has been broken will be considered conclusive evidence that the Pump has been altered or misused. Removal or damage to the Pump's serial number will invalidate this warranty.

D. Limitations and Exclusions: Repair or replacement of the Pump or any component part thereof is the EXCLUSIVE remedy offered by the Manufacturer. The following exclusions and limitations shall apply:

1. No agent, representative, or employee of the Manufacturer has authority to bind the Manufacturer to any representation or warranty, expressed or implied.

2. THERE IS NO WARRANTY OF MERCHANTABILITY OR FITNESS OR USE OF THE PUMP FOR ANY PARTICULAR PURPOSE.

3. The Pump can only be used under the supervision of medical personnel whose skill and judgment determine the suitability of the Pump for any particular medical treatment.

4. All recommendations, information, and descriptive literature supplied by the Manufacturer or its agents are believed to be accurate and reliable, but do not constitute warranties.

E. Computer Program License:

1. The Pump is intended to be used in conjunction with a particular Licensed Computer Program supplied by Manufacturer and use of any other program or unauthorized modification of a Licensed Computer Program shall void Manufacturer's warranty as set forth above.

2. The Original Purchaser and any users authorized by the Original Purchaser are hereby granted a nonexclusive, nontransferable license to use the Licensed Computer Program only in conjunction with the single Pump supplied by Manufacturer. The Licensed Computer Program is supplied only in machine-readable object code form and is based upon Manufacturer's proprietary confidential information. No rights are granted under this license or otherwise to decompile, produce humanly readable copies of, reverse engineer, modify or create any derivative works based upon the Licensed Computer Program.

3. All other terms and conditions of this Limited Warranty shall apply to the Licensed Computer Program. The Manufacturer disclaims responsibility for the suitability of the Pump for any particular medical treatment or for any medical complications resulting from the use of the Pump. The Manufacturer shall not be responsible for any incidental damages or consequential damages to property, loss of profits, or loss of use caused by any defect or malfunction of the Pump.

This warranty gives the Original Purchaser specific legal rights, and the Original Purchaser may have other legal rights which may vary from state to state.



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ZYNO MEDICAL Z-800 STATIONARY PUMP LIMITED WARRANTY Zyno Medical LLC (hereinafter referred to as “Zyno Medical”) warrants that:

• Each new Zyno Medical Z-800 infusion pump is free from defects in material and workmanship under normal use and service for a period of one (1) year from the date of delivery by Zyno Medical to the original purchaser.

• Each new accessory (including batteries) is free from defects in material and workmanship under normal use and service for a period of ninety (90) days from the date of delivery by Zyno Medical to the original purchaser.

If any product requires service during the applicable warranty period, the purchaser should communicate directly with their relevant account representative to determine the appropriate repair facility. Except as provided otherwise in this warranty, repair or replacement will be carried out at Zyno Medical’s expense. The product requiring service should be returned promptly, properly packaged and postage prepaid by the purchaser. Loss or damage in return shipment to the repair facility shall be at purchaser’s risk.

In no event shall Zyno Medical be liable for any incidental, indirect, or consequential damages in connection with the purchase or use of any Zyno Medical product. This warranty shall apply solely to the original purchaser. This warranty shall not apply to any subsequent owner of holder of the product. Furthermore, this warranty shall not apply to, and Zyno Medical shall not be responsible for, any loss or damage arising in connection with the purchase or use of any Zyno Medical product which has been:

• Repaired by anyone other than an authorized Zyno Medical service representative;

• Altered in any way so as to affect, in Zyno Medical’s judgment, the product’s stability or reliability;

• Subjected to misuse or negligence or accident, or which has had the product’s serial or lot number altered, affected, or removed.

• Improperly maintained or used in any manner other than in accordance with the written instructions furnished by Zyno Medical. This warranty is in lieu of all other warranties express or implied, and of all other obligations or liabilities of Zyno Medical and Zyno Medical does not give or grant, directly or indirectly, the authority to any representative or other person to assume on behalf of Zyno Medical any other liability in connection with the sale or use of Zyno Medical products.

Zyno Medical DISCLAIMS ALL OTHER WARRANTEIS EXPRESS OR IMPLIED, INCLUDING ANY WARRANTY OF MERCHANTABILITY OR OF FITNESS FOR A PARTICULAR PURCHASE OR APPLICATION.

KANGAROO JOEY ENTERAL PUMP LIMITED WARRANTY 1. Covidien warrants to the original purchaser (“Customer”) that this newly manufactured enteral feeding pump (“Pump” or “Pumps”) will be free of defects in materials and workmanship, under normal use, for three (3) years from the date of shipment from Covidien. This Limited Warranty as applied to pump batteries and power cords is limited to one (1) year from the date of shipment from Covidien for all pumps.

2. This Limited Warranty does not extend to routine maintenance of pumps such as cleaning and all recommended performance tests set forth in this pump operation and service manual which remain the sole responsibility of Customer. Failure of Customer to perform cleaning, routine maintenance and recommended performance testing on any pump as outlined in this pump operation and service manual may void this Limited Warranty.

3. Customer agrees that, with the exception of customer serviceable parts and troubleshooting steps outlined in this pump operation and service manual, Covidien or its authorized dealer must perform pump repairs.

4. This Limited Warranty does not cover any pump, product or part that: (a) has been operated in an unsuitable environment or used for purposes other than intended; (b) has been subjected to unauthorized or non-Covidien repair or use of non-Covidien supplied parts; (c) has been altered, misused, abused or neglected; (d) has been subjected to fire, casualty or accident; (e) suffers damage caused by Customer’s negligent acts or omissions; or (f) suffers damage beyond normal wear and tear.

5. For purposes of this Limited Warranty, “damage beyond normal wear and tear” includes without limitation: (a) Damage to housing, LCD, display overlay or power supply; (b) PCBA damage due to fluid ingress; (c) Use of non-qualified power supply or battery; or (d) Use of unauthorized cleaning fluids.

6. If a pump does not operate as warranted during the applicable warranty period, Covidien may, at its option and expense, (a) repair or replace the defective part or pump; or, (b) refund to Customer the purchase price for the defective part or pump.

7. Dated proof of original purchase is required to process warranty claims. Removal, defacement or alteration of serial lot number voids this Limited Warranty.

8. Shipping costs for pumps being returned to Covidien shall be borne by Customer. Customer is responsible for proper packaging for return shipment. Loss or damage in return shipment to Covidien shall be at Customer’s risk.

9. Covidien disclaims all other warranties, expressed or implied, including any implied warranty of merchantability or fitness for a particular purpose or application other than as expressly set forth in the product labeling. In no event shall Covidien be liable for any incidental, indirect or consequential damages in conjunction with the purchase or use of the pump, even if advised of the possibility of the same.



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ENTRALITE INFINITY ENTERAL PUMP LIMITED WARRANTY Solely for the benefit of the original buyer, Moog Medical Devices Group (“Moog”) warrants all new EntraLite Infinity products of its manufacturer (hereafter “Products”) to be free from defects in material and workmanship, and will replace or repair, F.O.B., at its factory in Salt Lake City, Utah, or other locations designated by Moog, any Products returned to it within (24) twenty four months of original purchase by the buyer. Such repair or replacement shall be free of charge.

Moog warrants the original buyer, that the Moog-repaired portion of the Products, or replaced Products will be free defects in material and workmanship, and Moog will replace or repair defective Products. F.O.B., at its factory in Salt Lake City, Utah, or other locations designated by Moog. Such Moog-performed repair or replacement shall carry a warranty of ninety (90) days from the date of repair or replacement or the balance of the new Product warranty as described above, whichever is greater.

This Warranty applies to all Products manufactured by Moog and is the ONLY WARRANTY GIVEN FOR THE SALE OF PRODUCTS OR SERVICES PERFORMED BY Moog. NO WARRANTIS IMPLIED IN LAW, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR PARTICULAR PURPOSE, SHALL APPLY. Moog WILL BE LIABLE, IN ANY EVENT, ONLY FOR THE PURCHAS PRICE OF THE DEFECTIVE PRODUCT, BUT NOT FOR ANY CONSEQUENTIAL, SPECIAL AND INCIDENTAL DAMAGES.

This warranty may not be modified, amended or otherwise changed, except by a written document properly executed by a duly authorized representative of Moog. In addition, this Warranty does not apply to Products that have been altered or repaired by personnel other than those employed by Moog; nor does it apply to Products that have been subjected misuse, abuse, neglect, improper operation of warranted Products contrary to applicable operation manuals, accident, improper maintenance or storage, Acts of God, vandalism, sabotage or fire.

This warranty is void if the Product is opened or tampered with in any way without prior authorization from Moog.

This warranty does not cover normal wear and tear and maintenance items, and specifically excludes batteries, administration sets, extension sets or any other accessory item used with the Products.

ENTRAFLO H20 ENTERAL PUMP LIMITED WARRANTY Medline Industries warrants the EntraFlo H20 Nutrition Delivery System against defects in material and workmanship under normal use and service for a period of one (1) year from the date of delivery. This warranty is valid only to the original purchaser and does not extend to any product or part thereof, which has been subjected to accident, abuse, alteration, misuse, or which has not been operated and maintained in accordance with prescribed instructions. This warranty shall not apply if the product has been repaired by anyone other than an authorized service representative of Medline Industries.

LIMITATION OF WARRANTY: The foregoing warranties are exclusive and in lieu of all other express, implied, and statutory warranties whatsoever, and Medline expressly disclaims all warranties or merchantability, noninfringement, and fitness for a particular purpose. Under no circumstance shall company have any obligation or liability for any loss of profit or for any consequential, incidental, indirect, special, punitive, or contingent damages whatsoever with respect of claims make hereunder or by and customer, consumer, or other use of company products. In the event that any applicable laws impose warranties, condition or obligations that cannot be excluded or modified, this paragraph shall apply to the great extent allowed by such laws.

1557 Winchester Ave, Ashland, KY 41101. Local Phone: 606 ...

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