Duties of position
To provide nursing care in accordance with the client's plan of care to include comprehensive health and psychosocial evaluation, monitoring of the client’s condition, health promotion and prevention coordination of services, teaching and training activities and direct nursing care.
1. Coordinates total patient care by conducting comprehensive health and psychosocial evaluation, monitoring the client's condition, promoting sound preventive practices, coordinating services and teaching and training activities.
2. Evaluates the effectiveness of nursing service to the patient and family.
3. Prepares and presents patient's record at Agency case conference and to the QAPI team as indicated.
4. Consults with the attending physician concerning alterations of patient care plans, checks with the appropriate supervisor and makes changes, as appropriate.
5. Submits clinical notes according to company policy.
6. Participates in case conferences, discusses with the supervisor problems concerning the patients and how they may best be handled.
7. Discusses with the appropriate supervisor the need for the involvement of other members of the health team such as the Home Health Aide, the Physical Therapist, the Speech Therapist, the Occupational Therapist, the Medical Social Worker, etc.8. Administers IM medications, performs lab draws and specimens collections, and educates patient and caregiver in appropriate medical techniques.
8. Obtains orders for HHA services and submits a referral to the appropriate personnel.
9. Participates in the patient’s discharge planning process.
10. Cooperates with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive care plan.
11. Participates in staff meetings and case conference.
12. Continually strives to improve his/her nursing care skills by attending in-service education, through formal education, attendance at workshops, conferences, active participation in professional and related organizations and individual research and reading.
13. Participates in the development and periodic revision of the physician's Plan of Treatment and processes change orders as needed. Integrates orders into the plan of care as necessary.
14. Participates and plans appropriate discharge goals at time of start of care, with realistic, patient appropriate time frames for accomplishment and monitors and documents progress towards goals throughout the Agency episode of care.
15. Maintains an on-going knowledge of current drug therapy.
16. May be requested by Director of Clinical Services (DCS) to fill in for the other nurses.
Coordinates the Admission of a Patient to the Agency
1. Conducts an initial and ongoing comprehensive assessment of the client’s needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points.
2. Obtains a medical history from the patient and/or a family member particularly as it relates to the present condition. Plan of care and teaching methods that will be most effective based on evaluation. Coordinates all services ordered through the Agency’s designed process and monitors services provided for appropriateness and for progress towards designed goals.
3. Evaluates the patient's environment to determine what assistance will be available from family members in caring for the patient.
4. Evaluates the patient's condition and home situation to determine if the services of a Home Health Aide will be required and the frequency of this service and obtains physician order for such. Will integrate all orders into the patient’s plan of care and alert all physician’s involved in the patient’s plan of care of new interim orders.
5. Explains nursing and other Agency services to patients and families as a part of planning for cares well as including them in the development of the plan of care.
6. Develops and implements the nursing care plan.
Provides Skilled Nursing Care as Outlined in the Nursing Plan of Care
1. Nursing services, treatments and preventative procedures requiring substantial specialized skill and ordered by the physician.
2. The initiation of preventative and rehabilitative nursing procedures as appropriate for the patient's care and safety.
3. Observing signs and symptoms and reporting to the physician reactions to treatments, including medications, as well as changes in the patient's physical or emotional condition.
4. Teaching, supervising and counseling the patient and caregivers regarding the nursing care needs and other related problems of the patient at home.
5. Supervises and evaluates the care given by the Home Health Aide as needed, and at a minimum of once every 14 days.
6. Submits to the appropriate department/individual a written evaluation of the Home Health Aides who are providing service to the patients in his/her geographical area.
7. Participates in periodic conferences with the DCS concerning the Aide's performance.
8. Charts those services rendered to the patient by the staff nurse and changes that have been noted in the patient's condition and/or family and home situation. Makes revisions in the nursing care plan as needed. Records supervisory visits conducted with the Home Health Aide. Evaluates patient care and progress and closes charts of discharged patients.
9. Evaluates the effectiveness of nursing service to the individual and family.
10. Consults with the attending physician concerning alteration of the plan of treatment in consultation with the supervisor.
11. Updates supervisor daily on visits made.
12. Discusses with the supervisor problems concerning the patients and possible resolutions.
13. Provides guidance and supervision to the LPN and supervises the LPN every 30 days.
14. Participates in the planning, operation and evaluation of the nursing service.
15. Participates in the development and periodic revision of the physician’s Plan of Treatment and processes change orders as needed.
16. Participates in the patient’s discharge planning.
17. Prepares the care plan for the Home Health Aide.
18. Awareness of the Agency’s QAPI program. Active participation as required per policies and procedures related to the Agency’s QAPI program.
19. Management and follow up of customer complaints, following Agency’s complaint policy.
20. Acute awareness of patient rights and the Agency’s responsibility in honoring patient’s rights. Awareness of patient rights description in Agency’s service agreement and Agency’s admission packet.
21. Awareness of appropriate reasons for a patient discharge and Agency’s policy on appropriate reasons for discharge.
22. Awareness of potential signs of abuse and neglect and the steps required to report suspected abuse and neglect.
23. Awareness and ability to design and identify patient centered and individualized goals with realistic measurable time frames under the supervision of a Registered Nurse.
24. Awareness of infection prevention and control techniques, both within their scope of practice and within the Agency’s policy and procedures. Awareness and participation in the Agency’s infection control program.
25. Nursing bag technique policy acknowledgement and demonstrated competence.
1. Must have a driver’s license and be willing and able to drive to client’s residences.
2. The ability to access clients’ homes which may not be routinely wheelchair accessible is required. Hearing, eyesight and physical dexterity must be sufficient to perform a physical assessment of the client's condition and to perform and demonstrate client care.
3. Physical activities will include, walking, sitting, stooping, and standing and minimal to maximum lifting and turning of clients.
4. The ability to communicate both verbally and in writing is required as frequent communication by telephone and in writing is involved.
Thermometer, B/P cuff, glucometer, penlight, hand washing materials, PPE
Has access to all client medical records, personnel records and client financial accounts which may be discussed with the DCS.
1. Must be a Registered Nurse licensed by the state.
2. Must be licensed in the State as a Registered Nurse.
3. Must have one or more years in home health agency or in a facility setting.
4. Must have knowledge of Medicare and Medicaid guidelines.
5. Must have a working knowledge of home health care and the principles and techniques of professional nursing and required documentation that pertains to it.
6. Should be skillful in organization and in the principles of time management and have knowledge of management processes.
7. Must be able to contribute to the quality of care being rendered through constructive communication with nursing managers and staff.