Are You an Entrepreneur or a Small Business Owner?

Do you want to be an Entrepreneur or a Small Business Owner? Is there a difference, and does it matter?

There is a difference, and it’s easy to confuse the two or use the two terms interchangeably. A Small Business Owner owns their own business, but also actively participates in that business. Often the Small Business Owner is critical to the ongoing success of the company. Without him or her, the business either does not exist (i.e. medical, legal, accounting, consulting, freelancing) or would suffer greatly in the owner’s absence for any period of time.

We often use the term “Solopreneur” to refer to the individual practitioner who is their own boss but must personally deliver a service or create a product for their business to generate revenue. While this may certainly be better than working for someone else, it’s still about trading time for money – and time is our most limited resource.

Whether you are a Solopreneur or a Small Business Owner, you likely own a business that depends primarily on you. Perhaps the business is run by you and a couple of other founders. The point is, only a few people know and can execute on the secret recipe at the foundation of your business. And those key people must be present for the business to operate. An Entrepreneur instead builds a business and supporting systems that are independent from the founder. The founder may well be an integral (or exclusive) part of the businesses initially, but the goal is always to grow the business to the point where the owner does not have to be involved in day-to-day operations. When you build a business that continues to generate revenues in your absence, then you have created a truly leveraged model and can call yourself an Entrepreneur.

Many of us start as Small Business Owners, enjoy success, and grow our companies. We may then move on to creating a larger business that does not require us to be present, and we graduate to the level of Entrepreneurship. If we repeat this multiple times, then we may call ourselves Serial Entrepreneurs.

“Entrepreneurship is the pursuit of opportunity without regard to resources currently controlled.”
Howard Stevenson, Harvard Business School Professor.

You may not be clear at the start as to which one you want to grow up to be, an Entrepreneur or a Small Business Owner. But by asking yourself a series of hard questions, and honestly assessing your true desires, you are more likely to start a business that suits you best. And it’s certainly acceptable if you want to be Small Business Owner… we are not saying that’s a bad thing. But it’s important for you to begin understanding the difference between the two as it may impact the type of business you build and how you plan to develop it.

It’s also important to avoid creating another low-paying harder-working “job”, like the one you may already have! Michael Gerber explains this situation best in his seminal book “The E-Myth”. This book is a must read for small business owners, with one of its major themes being the difference between working “in” your business (you make the pies) versus working “on” your business (others make the pies following your recipe and systems).

As you prepare to become your own boss, or if you have already started a small business, it’s important to keep your long-term vision in mind. Doing so will help you determine the type of business you start and build, helping ensure that you achieve your definition of success.

Do you want to be an Entrepreneur or a Small Business Owner? Here are some questions to ask to help you determine want you really want:

  1. Do you want to own just one or two locations (i.e. one or two franchise units, or your own practice) or do you want to create something bigger with multiple locations and perhaps grow internationally (i.e. offer franchises and hire others to run the business)?
  2. Do you want to work in the business (i.e. make the donuts) or do you want to have someone else manage the day-to-day operations (i.e. someone else makes the donuts following your instructions)?

  3. Are you looking for a job or are you looking to create a self-managing company (a business that does not rely on your day-to-day presence for success)?
  4. Do you prefer to create or do you enjoy executing?
  5. Do you envision creating multiple different businesses across multiple industries?
  6. Are you able to let go of all of the details, or are you a micro-manager?
  7. Are you the only person who can deliver your service or product, or can you teach others how to do it?
  8. Is your goal to work hard until a certain age and then retire, or continue creating and leading your businesses until you are no longer mentally capable?
  9. Can you sell your business as it currently operates and without you having to continue being part of it?

Eight Tips For Launching Your Real Estate Investing Career

Eight Tips for Getting Started in Real Estate Investing

Introduction

This article is just the basics for getting started in real estate investing. This is not a how to article but an article that gives you some information about things to do to get started. Everything in this article is tools that can be applied to helping anyone get started in real estate investing. I am going to give you my eight keys to getting started. Nothing is right or wrong but reflects the point of view of the author. Laws and legal practices vary from state to state, and laws can change over time. The author does not vouch for the legality of his opinions, nor is there any intent to supply legal advice. The author strongly encourages the reader to consult with professionals and an attorney prior to entering in any real estate transaction or contract. The author is not a writer but he is a real estate investor. There will be grammar mistakes and errors, so don’t be too critical of the grammar but focus your energy on what is being said. With that said prepare yourself to think a little differently and expand your mind. Let’s get started on an amazing adventure.

The Eight Tips are as follows

1. Desire
2. Goal Setting
3. Learning What To Do
4. Attending a Real Estate Investing Seminar
5. The Billings Montana Market
6. Finding a Mentor
7. Your Real Estate Team
8. Just Do IT

1. Desire

Before we get in to the bolts and nails of real estate investing in I want to talk to you about desire. If you are going to be successful at anything in life including real estate investing you have to have the desire to do it. Desire is defined as longing or craving, as for something that brings satisfaction or enjoyment. Desire stresses the strength of feeling and often implies strong intention or aim. In real estate investing if you don’t have a desire to learn and grow as a human being and really get satisfaction out of it, then real estate investing is going to be hard to do. When I go out and look at a property it brings me a lot of enjoyment. Every aspect brings me joy from talking to home owners, figuring out how I can make a deal work, to buying the house and to finding a good homeowner or tenant for the house. Real estate investing may not be for everyone but real estate investing can offer anyone the financial freedom we all crave for. If you do not have the desire for real estate investing that is ok, it can still help you to live your dreams and help you to get where you want to go in the future.

Why is real estate investing an amazing avenue for anyone to live out all of their dreams? Let me ask you a few questions. Do you have enough money to do anything you want? Do you have everything you want? No debt? A nice house? Great Marriage? The freedom to do anything regardless of how much it costs and the time it takes? If you have all of these things then you are one of the few people in America who does. Most people may be working fifty hours a week and making just enough to pay their bills. In today’s day and age most people are living pay check to pay check never really knowing if they will make enough to pay the bills that just keep piling up. If you cannot keep up with your monthly bills how are you going to plan for retirement or send your kids to college or have time to enjoy life. The answer to all of these questions is becoming financially free. Now it’s not going to be easy everyone will have to get off the couch and out of their comfort zone. Real estate is proven to be one of the fastest ways to get your out of the rat race of the nine to five and begin living the life you deserve to live. Everyone wants something different out of their life. Some dream of traveling the world, spending more time with family, volunteering, golfing, laying on a beach, giving back to the community, or anything that will make them happy. There are thousands of things that make people happy.

Making it in real estate takes a person who has a strong desire to change their lives for the better and think big. Anyone can become a great real estate investor. It is going to take a lot of work and can be a struggle at times but in the end it will be the most amazing feeling ever. The people that make it in real estate investing all have a few things in common. First they run their real estate investing business like any other business out there. Second they get out there and network with anyone and everyone. Some people might be like me and have a hard time talking to other people. If you are that is ok, anyone can learn how to become a people person, it just takes hard daily work. You have to push yourself past your comfort zone. The third thing is that you cannot be afraid to fail. Everyone has failed at something but the most successful people out their learn from their failures. The fourth thing is that you have to put a good team together. I will go into putting a team together in a later chapter. The concept of putting a team together is so that when you don’t know something you have team members that know what to do and can help you with questions. The can also make sure that you are not working yourself to death. You do not want to be the person doing everything in your business. Doing everything is a receipt for failure. You have to put together good people who you can trust and rely on. The fifth thing is that you need a mentor. Sixth and final is the desire to do it. No one can become successful at something if they don’t want to do it and don’t get satisfaction out of what they are doing.

2. Setting Goals

Having goals is one of the most important aspects of achieving what you want in life. You don’t want to just have your goals up in your head you want to write them down and past what you have wrote on the wall somewhere or in the bathroom mirror. You want to review your goals daily and read them out loud to yourself. This way you remind yourself everyday why you are building your business.

How should you start to write down you goals? First off you should think big, and by big I mean HUGE. If your goals are too small you will easily achieve them and have nothing else to look forward too. You should start off by asking yourself the question if I had all the money and time in the world what would I do, what would I buy, how would I spend my time, and how would I spend my energy. Are you starting to write these down? Well you should be. Think about what you want, spending time with family, traveling the world, the best cars, a castle, owning a small country, running for president, having the biggest real estate investing business in your area or in the country. Whatever your dreams and what you want out of your life, write it down. Some of my goals are becoming free, traveling the world, having a Ferrari, having 10 vacation homes all over the world. Right now I am just trying to get you out of your comfort zone of thinking and let your imagination run. There are several ways to set goals. I have learned a lot of ways you can set you goals and there is no right or wrong way. The best ways that I have found to set your goals is to break them up into two categories. First your short term goals. This should be goals from a month out to around a year. The second is your long term goals these goals are you think big goals and what you see for your future.

For year one I like to first make a list of what I want to achieve this year and I will give you an example of how to do that. For year one you want to be very specific first you want to list what you want your income to be at the end of the year, next how much cash in the bank you want (this is money in your checking account, not assets). Next you want to list how much you are going to give. Giving is a very important, this can be giving to charity, giving of gifts to friends and family, giving to your school or anything you can dream of. As long as what you give brings joy to others who need it more than you. Next list what bad habits you have that you want to eliminate. Weather is be quitting smoking, spending too much on junk, drinking too much, working too much, not spending enough time with family, too much TV, not exercising and many more. We all have bad habits that need to be changed in order for use to grow as human beings. Under each of these bad habits list out some steps that you can take in order to quit them. If you bad habit is being lazy and not exercising enough what can you do to change that. Well you can get a gym membership or a home work out program. Commit yourself you following through with a plan to work out 3-5 days a week. For you to change these bad habits you have to be totally committed and follow through with a detailed plan you set for yourself. After you have your plans in place you should start listing several things you want to achieve or do in the next year. This can be start a successful business, spend time with family, travel to 2-5 places and so on. Now under each of these you should also write a detailed plan on what you need and what you need to do in order to achieve these goals. Finally you should take all of this information you have a write on page on what you see your life being over the next year. Doing this is a great exercise to really see what you want out of life.

Goals Year One

This is what I am going To Do This Year
Income: $500,000
Cash: $100,000
Give: $20,000

Bad Habits that will be changes:

Over Sleeping 1. Go to bed at 11 p.m. 2. Use a timer and set it for 8 hours 3. Set the timer on the other side of the room

Buying things that you don’t need: 1. Going out shopping less 2. If you have the urge to buy something think to yourself is thing item going to help me to achieve my goals of becoming financially free? 3. Tell friends what you are doing, so they can help to stop you.

What I want to Achieve:

Start a successful Real Estate Investing Business: (you should write a detailed step by step plan of everything you need in order to achieve your goal)

Travel: Where do I want to visit? 1. Gators football game (what I need to do it, money, etc)

And last your own page about what you want to achieve using words like I will and only positive words.

For long term goals you don’t need to be as specific right now, but you should list them and under them list a few steps or smaller goals that need to be achieved before you are able to achieve them. With the long term goals always think big. Another good exercise for long term goals is to make a collage of you goals. Put pictures of the house you want on it, places you want to travel, a picture of your family, a number of what income you want in or anything you can think of.

3. Learn

Knowledge builds confidence and destroys fear. If you are starting any kind of business you need to learn the ins and outs of that business. The best way I have found to learn about real estate investing is to read all about it. But once you know it you have to apply what you have learned. Learning and reading is just one step to take. There are thousands of books on the market about real estate investing and everyone has something you can learn from. You don’t just want to read real estate investing books though. You also want to fill yourself with motivational and leadership books. Every successful person that I know if a reader and they all spend at least thirty minutes a day reading something that will teach them about improving their business or helping themselves to become a better person. Some of the best books that I would recommend reading are listed below.

1. Rich Dad Poor Dad by Robert Kiyosaki (read this first and also ready everything in the rick dad poor dad series, great books to start with and will expand you mind)
2. Be a Real Estate Millionaire by Dean Graziosi
3. Flip your way to financial freedom by Preston Ely (this is an E-Book)
4. Four hour work week by Timothy Ferriss
5. The Attractor Factor
6. Short Sale Pre-foreclosure Investing by Dwan Bent-twyford and Sharon Sestrepo
7. Keys to success, by Napoleon Hill
8. Think and Grow Rich by Napoleon Hill
9. How to win friends and influence people
10. Any Book by John C. Maxwell (he has tons of amazing leadership books)
11. Getting Started in Real Estate Day Trading by Larry Goins
12. The E Myth by Michael Gerber
13. How to be a quick turn real estate millionaire by Ron Legrand
14. The Power of Full Engagement
15. The It Factor
16. Anything by Anthony Robins

There are tons more you can read but these will give you a great start. You should also read books on negotiating, sales, motivation, and biographies on American business people.

I hope this list gives you the knowledge it has given me. If you learn and apply what you have learned from these books there is no reason that you should not become very successful.

4. Attend a Real Estate Investing Seminar

Attending a Real Estate Investing Seminar can be one of the best places to learn about real estate investing from some very well known experts. There are several seminars going on all over the country every weekend. If you live in a big city it will be very easy to find one. If you live in a town like Billings Montana you might need to travel a little ways to find one. Now most of the best meeting cost money to attend them. Some range from five hundred dollars for three days and some can be up to $20,000. There are a few that I would recommend. Than Merrill is a great speaker to go hear. I have learned a ton from him. You can find his company online by Google searching him. Also rich dad poor dad has seminars all over the country. I attended one of their seminars in Billings Montana for only $500 dollars and learned a ton from it. There is also Preston Ely, Larry Goins, and hundreds of speakers out there. If you find a great book that you really enjoyed, then just simple search for that person online and see if they are speaking somewhere or offer a seminar close to you.

Another reason I recommend going to a seminar is because they get you pumped up and motivated. I have not yet found anything else that just gets you feeling like you can do anything. When you get back from one of these seminars you will have tons of energy and knowledge. Every time I get back from one all I want to do is going out and do a deal or ten.

These seminars will also provide you with several opportunities to purchase amazing real estate investing tools, software or learning material at a fraction of the cost. Believe me when I tell you all of the low priced seminars try to sell you something. But a lot of times what they are trying to sell is some really good stuff.

Another reason to attend a seminar is to network with other investors and build relationships with them. You can meet other investors who you can partner with on a deal, sell a deal too, people who will provide you with deals and so on. You should have hundreds of business cards made up and try to give them all out. You never know how much one business card you hand out can make you.

5. Learn About the real estate market in your area

Most real estate investors start their career off my investing around where they live. This is why I do my real estate investing in Billings Montana. You can venture out when you have more experience. The reason behind this is because we feel more comfortable with the areas and know the areas better. It is also easier to get local real estate information that we need. Investing in your local market is also cheaper to start out, there is less travel costs, you can see what you are buying and it may give you a feeling a comfort.

First you have to decide which part of town is the best place to invest in. This can be determined by what kind of real estate investing you choose to do. I have not gone over the types of real estate investing but some include rehabbing (fixing up and selling), wholesaling (finding deals and selling them to other investors), buying to rent, and there are a few others. These are the real estate strategies that I use for the most part. When looking at the market you need to see where other investors are buying their houses. Most of the best deals will be found in low to middle class neighbors hoods. By low I don’t mean drug infested war zones, what I mean is blue collar safe neighbor hoods that might have somewhat older houses and houses that are not on the higher end price side. Now you can find deals in the higher priced neighbor hoods but most will be in the low to middle income neighborhoods. When looking where others are buying ask local realtors, other investors or appraisers.

When talking with investors ask them several questions such as what neighborhoods they prefer, what type of houses they buy (3 bed 2 bath), and what they do (rehab, rent, wholesale). You should not look at other investors as competition but try and work with them.

There are different types of markets such as appreciating markets, flat markets, and deprecating markets. Appreciating markets are markets that there is no enough houses or a very high demand for houses which causes the price of houses to go up. The reason there is a high demand for housing can be because of job growth, a very appealing area, or several reason. Flat markets are markets that have no or very little growth. This means that there is not a lot of demand; buy just enough to fill every ones needs. Depreciating markets are where there is a lot more houses than people to fill those house. This causes house prices to start going down. This can be because of a large employer leaving the area, a natural disaster or just over building. There is an old saying buy in a bust and sell in a boom. In depreciating markets you can pick up several deals, while in appreciating the house prices are going to be much higher and harder to find great deals. The deal will still be out there you just have to know where to find them.

Learning your market is another key to becoming successful. Real estate Brokers and experts in your area can be the best source of information for you. Learn to use them to find out what kind of market you are in. If you are in Billings Montana we are in a pretty stable market. Billings Montana has not seen the ups and downs that other markets have experienced. I will have to say that I have been noticing a little bit of a downward trend but not much. Once the first time home buyer credit is over with we might see a little more decline. Every market can vary by neighborhood, so make sure you know you market well. I have seen the same houses just one mile apart selling for totally different prices. 6. Find a Mentor

Having a mentor to help you can be your biggest learning experience. Mentors can help you with any questions you may have, walk you step by step through the investing process, give you moral support, you learn from their proven system, and also network you with others in the business. Every successful real estate investor that I know says they owe a lot of their success to the mentors they have and had in their lives. I have had one of the best mentors around, my father. He is teaching me something new every day and pushing me to become successful.

When trying to find a mentor I would suggest network with the investors at your local real estate investors club meeting. There is a real estate investing club in Billings Montana that meets once a month. You can find information about real estate investing clubs in your area by searching for REA or real estate investors club then your area in Google. When you go to the meetings ask around who the biggest investors are. Then ask if you could get together with them sometime and discuss real estate investing. Ask them if they would consider working with you to get their career going. Offer your services as a bird dog. Bird dogs are people who go out find deals or leads about deals and give them to other investors. A bird dog gets from $500 to $3000 dollars depending on the deal. Make sure that you have a bird dog contract signed with the investors saying that if you find them and deal and they buy it that you get paid a certain amount of money. Being a bird dog helps you to build credibility with the investor and they are more likely to mentor you if you have something to offer them. If you would like to contact me with a question go to my web site Big Sky Property Solutions LLC.

7. Your Real Estate Team

Building an effective team can make your life as a real estate investor a lot easier. You are only one person and cannot do everything or be an expert in every aspect of real estate investing. Going at a project alone can become one of the most frustrating experiences you will ever encounter. Many people have become frustrated and quite real estate investing because they try and juggle too many things. Make sure that when putting a team together you provide everyone with win-win opportunities. When someone knows that working with you is going to make them money they will put you as a higher priority on their list. But you have to prove it to them that you are the real deal.
People to have on your real estate investing team include

o Real Estate Agents ( find the top agent for volume of sales in your area and other agents who work with real estate investors)
o Real Estate appraisers (find an appraiser that has done a few hundred jobs or more and make sure they carry errors and omissions insurance)
o Real estate contractors (good rehab crews that can get the job done in a timely manner, have 3-5 crews and on every deal get 3 estimates done. Ask for referrals from them and make sure they are licensed)
o Real estate attorneys (every investor needs an attorney, they can help to protect your assets, make sure you find one that works with investors)
o A property management company (can manage your properties and will give you leads on property they are managing that might come up for sale)
o Title companies (take care of the legal process and make sure there are no liens against the property you are buying, choose one that does hundreds of closings a year)
o Home inspectors(charge about $400 but will give you a great inspection and could save you thousands in the long run)
o And your Mentor

All of these people can help you in various aspects of real estate investing. You might find that there are a couple others that are keys to your business but this is just a list of a few.

8. Just Do it

There is no better phrase out there then JUST DO IT! Once you have learned all you can networked with investors in Billings and learned real estate investing strategies there is nothing left to do but get your feet wet. There is no better learning tool out there then doing a deal. Once you have completed that first deal you will know what to expect and find out that it is not as hard as you thought it would be. You will have learned what you did right and what was frustrating. Take that experience and ask yourself what would have made it run smoother. Apply that to your next deal. Then the next deal will be easier and it keeps getting easier as you go. I will say that every deal is different from the last but that what makes this business fun. You have to be creative and always keep on learning and growing with your business.

The average person never uses what they learn. Don’t be average apply your knowledge. When going out and doing your first deal act like you have done 1000’s of deals. The fastest way to change a habit is to act like it is true.

Five keys for success
1. Specialized Knowledge
2. Tools of a professional
3. Have the mindset of a winner
4. Mentors
5. Money and the knowledge of leveraging it (you don’t have to have millions to invest in real estate, there are many strategies out there to use other people’s money, or no money at all)

This is going to conclude this article about getting started in real estate investing. I hope this gave you some ideas about how you can get started. I didn’t give you any strategies at this point but look for some in upcoming articles. These are simple steps you can use to get started. If you read this article thank you for listening.

Patient Abandonment – Home Health Care

Elements of the Cause of Action for Abandonment

Each of the following five elements must be present for a patient to have a proper civil cause of action for the tort of abandonment:

1. Health care treatment was unreasonably discontinued.

2. The termination of health care was contrary to the patient’s will or without the patient’s knowledge.

3. The health care provider failed to arrange for care by another appropriate skilled health care provider.

4. The health care provider should have reasonably foreseen that harm to the patient would arise from the termination of the care (proximate cause).

5. The patient actually suffered harm or loss as a result of the discontinuance of care.

Physicians, nurses, and other health care professionals have an ethical, as well as a legal, duty to avoid abandonment of patients. The health care professional has a duty to give his or her patient all necessary attention as long as the case required it and should not leave the patient in a critical stage without giving reasonable notice or making suitable arrangements for the attendance of another. [2]

Abandonment by the Physician

When a physician undertakes treatment of a patient, treatment must continue until the patient’s circumstances no longer warrant the treatment, the physician and the patient mutually consent to end the treatment by that physician, or the patient discharges the physician. Moreover, the physician may unilaterally terminate the relationship and withdraw from treating that patient only if he or she provides the patient proper notice of his or her intent to withdraw and an opportunity to obtain proper substitute care.

In the home health setting, the physician-patient relationship does not terminate merely because a patient’s care shifts in its location from the hospital to the home. If the patient continues to need medical services, supervised health care, therapy, or other home health services, the attending physician should ensure that he or she was properly discharged his or her-duties to the patient. Virtually every situation ‘in which home care is approved by Medicare, Medicaid, or an insurer will be one in which the patient’s ‘needs for care have continued. The physician-patient relationship that existed in the hospital will continue unless it has been formally terminated by notice to the patient and a reasonable attempt to refer the patient to another appropriate physician. Otherwise, the physician will retain his or her duty toward the patient when the patient is discharged from the hospital to the home. Failure to follow through on the part of the physician will constitute the tort of abandonment if the patient is injured as a result. This abandonment may expose the physician, the hospital, and the home health agency to liability for the tort of abandonment.

The attending physician in the hospital should ensure that a proper referral is made to a physician who will be responsible for the home health patient’s care while it is being delivered by the home health provider, unless the physician intends to continue to supervise that home care personally. Even more important, if the hospital-based physician arranges to have the patient’s care assumed by another physician, the patient must fully understand this change, and it should be carefully documented.

As supported by case law, the types of actions that will lead to liability for abandonment of a patient will include: • premature discharge of the patient by the physician

• failure of the physician to provide proper instructions before discharging the patient

• the statement by the physician to the patient that the physician will no longer treat the patient

• refusal of the physician to respond to calls or to further attend the patient

• the physician’s leaving the patient after surgery or failing to follow up on postsurgical care. [3]

Generally, abandonment does not occur if the physician responsible for the patient arranges for a substitute physician to take his or her place. This change may occur because of vacations, relocation of the physician, illness, distance from the patient’s home, or retirement of the physician. As long as care by an appropriately trained physician, sufficiently knowledgeable of the patient’s special conditions, if any, has been arranged, the courts will usually not find that abandonment has occurred. [4] Even where a patient refuses to pay for the care or is unable to pay for the care, the physician is not at liberty to terminate the relationship unilaterally. The physician must still take steps to have the patient’s care assumed by another [5] or to give a sufficiently reasonable period of time to locate another prior to ceasing to provide care.

Although most of the cases discussed concern the physician-patient relationship, as pointed out previously, the same principles apply to all health care providers. Furthermore, because the care rendered by the home health agency is provided pursuant to a physician’s plan of care, even if the patient sued the physician for abandonment because of the actions (or inactions of the home health agency’s staff), the physician may seek indemnification from the home health provider. [6]

ABANDONMENT BY THE NURSE OR HOME HEALTH AGENCY

Similar principles to those that apply to physicians apply to the home health professional and the home health provider. A home health agency, as the direct provider of care to the homebound patient, may be held to the same legal obligation and duty to deliver care that addresses the patient’s needs as is the physician. Furthermore, there may be both a legal and an ethical obligation to continue delivering care, if the patient has no alternatives. An ethical obligation may still exist to the patient even though the home health provider has fulfilled all legal obligations. [7]

When a home health provider furnishes treatment to a patient, the duty to continue providing care to the patient is a duty owed by the agency itself and not by the individual professional who may be the employee or the contractor of the agency. The home health provider does not have a duty to continue providing the same nurse, therapist, or aide to the patient throughout the course of treatment, so long as the provider continues to use appropriate, competent personnel to administer the course of treatment consistently with the plan of care. From the perspective of patient satisfaction and continuity of care, it may be in the best interests of the home health provider to attempt to provide the same individual practitioner to the patient. The development of a personal relationship with the provider’s personnel may improve communications and a greater degree of trust and compliance on the part of the patient. It should help to alleviate many of the problems that arise in the health care’ setting.

If the patient requests replacement of a particular nurse, therapist, technician, or home health aide, the home health provider still has a duty to provide care to the patient, unless the patient also specifically states he or she no longer desires the provider’s service. Home health agency supervisors should always follow up on such patient requests to determine the reasons regarding the dismissal, to detect “problem” employees, and to ensure no incident has taken place that might give rise to liability. The home health agency should continue providing care to the patient until definitively told not to do so by the patient.

COPING WITH THE ABUSIVE PATIENT

Home health provider personnel may occasionally encounter an abusive patient. This abuse mayor may not be a result of the medical condition for which the care is being provided. Personal safety of the individual health care provider should be paramount. Should the patient pose a physical danger to the individual, he or she should leave the premises immediately. The provider should document in the medical record the facts surrounding the inability to complete the treatment for that visit as objectively as possible. Management personnel should inform supervisory personnel at the home health provider and should complete an internal incident report. If it appears that a criminal act has taken place, such as a physical assault, attempted rape, or other such act, this act should be reported immediately to local law enforcement agencies. The home care provider should also immediately notify both the patient and the physician that the provider will terminate its relationship with the patient and that an alternative provider for these services should be obtained.

Other less serious circumstances may, nevertheless, lead the home health provider to determine that it should terminate its relationship with a particular patient. Examples may include particularly abusive patients, patients who solicit -the home health provider professional to break the law (for example, by providing illegal drugs or providing non-covered services and equipment and billing them as something else), or consistently noncompliant patients. Once treatment is undertaken, however, the home health provider is usually obliged to continue providing services until the patient has had a reasonable opportunity to obtain a substitute provider. The same principles apply to failure of a patient to pay for the services or equipment provided.

As health care professionals, HHA personnel should have training on how to handle the difficult patient responsibly. Arguments or emotional comments should be avoided. If it becomes clear that a certain provider and patient are not likely to be compatible, a substitute provider should be tried. Should it appear that the problem lies with the patient and that it is necessary for the HHA to terminate its relationship with the patient, the following seven steps should be taken:

1. The circumstances should be documented in the patient’s record.

2. The home health provider should give or send a letter to the patient explaining the circumstances surrounding the termination of care.

3. The letter should be sent by certified mail, return receipt requested, or other measures to document patient receipt of the letter. A copy of the letter should be placed in the patient’s record.

4. If possible, the patient should be given a certain period of time to obtain replacement care. Usually 30 days is sufficient.

5. If the patient has a life-threatening condition or a medical condition that might deteriorate in the absence of continuing care, this condition should be clearly stated in the letter. The necessity of the patient’s obtaining replacement home health care should be emphasized. 6. The patient should be informed of the location of the nearest hospital emergency department. The patient should be told to either go to the nearest hospital emergency department in case of a medical emergency or to call the local emergency number for ambulance transportation.

7. A copy of the letter should be sent to the patient’s attending physician via certified mail, return receipt requested.

These steps should not be undertaken lightly. Before such steps are taken, the patient’s case should be thoroughly discussed with the home health provider’s risk manager, legal counsel, medical director, and the patient’s attending physician.

The inappropriate discharge of a patient from health care coverage by the home health provider, whether because of termination of entitlement, inability to pay, or other reasons, may also lead to liability for the tort of abandonment. [8]

Nurses who passively stand by and observe negligence by a physician or anyone else will personally become accountable to the patient who is injured as a result of that negligence… [H]ealthcare facilities and their nursing staff owe an independent duty to patients beyond the duty owed by physicians. When a physician’s order to discharge is inappropriate, the nurses will be help liable for following an order that they knew or should know is below the standard of care. [9]

Similar principles may apply to make the home health provider vicariously liable, as well.

Liability to the patient for the tort of abandonment may also result from the home health care professional’s failure to observe, examine, assess, or monitor a patient’s condition. [10] Liability for abandonment may arise from failing to take timely action, as well as failing to summon a physician when a physician is needed. [11] Failing to provide adequate staff to meet the patient’s needs may also constitute abandonment on the part of the HHA. [12] Ignoring a patient’s complaints and failing to follow a physician’s orders may likewise constitute a tort of abandonment for a nurse or other professional staff member.

1. Lee v. Dewbre, 362 S.W.2d 900 (Tex. Civ. App. 7th Dist. 1962).

2. Kattsetos v. Nolan, 368 A.2d 172 (Conn. 1976).

3. 61 AM. Jur. 2d, Physicians and Surgeons § 237 (1981).

4. See, e.g., Tripp v. Pate, 271 S.E.2d 407 (N.C. App. 1980).

5. Ricks v. Budge, 64 P.2d 208 (Utah 1937).

6. M.D. Nathanson, Home Healthcare Answer Book: Legal Issues for Providers 212 (1995).

7. See, generally, E.P. Burnzeig, The Nurse’s Liability for Malpractice (1981).

8. Sheryl Feutz-Harter, Nursing Caselaw Update: In appropriate Discharging of Patients, 2 J. Nursing L. 49 (1995).

9. Id., 53.

10. See, e.g., Pisel v. Stamford Hosp., 430 A.2d1 (Conn. 1980) (nurses were held liable for failing to monitor the condition of a patient).

11. See, e.g., Sanchez v. Bay General Hosp., 172 Cal. Rptr. 342 (Cal. App. 1981); Valdez v. Lyman-Roberts Hosp., Inc. 638 S.W. 2d 111 (Tex. 1982).

12. Czubinsky v. Doctors Hosp., 188 CAl. Rptr. 685 (1983).

Buying Wine Online

With busy days the norm, the option to buy wine online helps to take some of your hassles away!

Buying wine online is hassle free. The shipping is a great convenience, purchasing is easy,
satisfaction is guaranteed and you don’t even have to leave the comfort of your own home.

Online merchants not only have a great selection of wines to choose from, they also provide a
multitude of reviews and customer ratings to help you make informed choices. Without the
overhead of brick and mortar stores they are able to offer great specials and unique products.

here are many sites on the internet that sell wine so before you buy make sure to check for the
following things Shipping – do they ship to your city and does your city allow you to receive wine?

Price – ensure you are getting the best price for your wine. You can do some great comparative

shopping ahead of time at There is of course no way to taste wine on the internet so read the reviews if you are
unsure about a wine. If this information is not provided on the site you are using try The Wine
Spectator for a detailed review of most wines.

Proof of Age – Be prepared to prove your age by fax or email.

Discounts – Most merchants will offer case discounts and they will usually allow you to purchase
a mixed case – these discounts are definitely worth your while so keep your eye out for them. Clubs – Wine clubs provide a great avenue to learn about wine. They give you a chance to
experience wines you may not find otherwise including new varietals, and exotic blends. Wine
clubs provide the ease and convenience of having wine delivered regularly with out any work on
your part.

For some of the more unique wines your best bet is still through the wineries themselves. Many
of them are now offering online ordering through their website so be sure to check out your
favorite vineyards.