Nursing Support Services

TSRN is dedicated to ensuring that individuals with special health care needs receive person-centered service delivery and are able to thrive in their communities. We offer several services to support individuals and family members who are managing care on their own (Self-Directed) in their own home or family home in a person-centered planning process.

Our Services

A Comprehensive Nursing Assessment includes:

  • Creating a Health Story
  • Review of Current diagnosis and Related Medication
  • Review of Side Effects from Medication Plan
  • Abilities and Strength Assessment
  • Health Risk Screening
  • Natural Supports and Back up Plans
  • Advanced Directives

“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.”

William A. Foster

Customized Person-Centered Care Plans

Provide a roadmap that clearly Identifies health and safety risk with strategies and objectives to prevent complications. These plans direct paid and unpaid caregivers, child care providers and family members in how to provide quality person-centered care that is both simple, safe and easy to follow.

Caretaker Care Plans
Individual Specific Trainings

Individual Specific Trainings

In collaboration with the primary caregiver or person, a training plan can be developed for all that care for the individual that includes techniques and skills competency checklist to ensure safe care is provided at all times topics include:

  • Basic Health and Safety
  • Personal Care routines

  • Mealtime management and modified diets
  • Adaptive Equipment
  • Lifting, transfers and positioning
  • Emergency medication administration- seizure, diabetes and asthma/allergy

  • And more
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Nursing Support Services

1. Nurse Consultation
2. Nurse Health Case Management/Delegation

The self-directed service delivery model is an alternative to traditionally delivered and managed services, such as an agency delivery model. Self-direction of services allows participants to have the responsibility for managing all aspects of service delivery in a person-centered planning process. (

Nurse Consultation

This Nursing Support Service model is used when the cognitively capable individual lives in their own home and manages his/her own health care, self-medicates or directs unpaid caregivers/family to manage medications and is exempted from delegation.

  • Comprehensive Nursing Assessment
  • Self Medication Administration Screening
  • HRST rating or RN Review annually
  • In collaboration with the individual and family may develop health protocols

    ○ May review case notes, appointments, labs, treatments

    ○ May follow up on previously identified issues, and supplement education provided to the individual/individual’s family.

    ○ May assist the individual in developing systems for monitoring individual’s health status and required follow up.

    ○ May provide information on basic health education related to diagnoses/healthcare protocols such as; basic nutrition, accessing community resources,emergency planning and resources ADL needs/positioning/transferring/skin care/etc, basic principles of selfadministration/administration of medication.

  • Collaborate with other team members.
  • Offer recommendations for resources related to health services for the individual.
  • Frequency of visits is up to 4 hours every quarter
  • Delegate medications or treatments
  • Review MARS (not required since no delegation)
  • Provide specific or generic training to staff
  • Supervise staff
  • Provide direct care
  • On call nurse availability
  • Care plan development
  • Health care case management
  • Visit or follow-up more often then quarterly

Nurse Health Case Management / Delegation

This Nursing Support Service model is used when unlicensed staff or family are being paid to give medication and/or provide other nursing task. The RN serves as the health case manager, delegating nurse and coordinates care for the individual.

  • Comprehensive Nursing Assessment,
  • Self Medication Administration Screening
  • Develop the Nursing Care Plan
  • HRST RN Review and Update
  • Provide an annual nursing report to the person centered planning(PCP) team
  • Nurse visits minimally every 45 days
  • On call nurse availabilty
  • RN Assess the environment to determine if safe for delegation.
  • RN determines appropriateness of delegation based on skills required to
  • provide care
  • RN determines level of staff needed to safely provide care
  • RN determines competency of staff, stability of the individual, stability
  • and safety of environment in which services are being received.
  • RN train, remediate and regularly supervise staff

    ○ staff may be:
    Certified Medication Technician
    Certified Nursing Assistant
    Unlicensed Assistant Personnel (UAP)/ No certifications

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Caring For Disabled Child
Nursing Support Service Nurse Consultation Nurse Delegation
Comprehensive Nursing Assessment x x
Self Medication Administration Screening x x
Develop the Nursing Care Plan   x
Assist the individual/family to develop healthcare protocols x  
HRST RN Review and Update x x
Provide an annual nursing report to the person centered planning(PCP) team   x
Nurse visits minimally every 45 days   x
Nurse visits up to 4 hours every quarter x  
On call nurse availability   x
RN train, remediate and regularly supervise staff   x
RN supervise medication administered by paid staff   x
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