PURPOSE OF POSITION

Under the direction of the supervising Assistant Director of Nursing in Community Care, provides community-based professional nursing care to patients in group and private homes, as well as those without housing across New York City. Diagnoses and treats responses to actual or potential health problems by means of nursing methods and techniques such as case-finding, health teaching, health counseling and the provision of care supportive to and restorative of life and well-being. Assesses, plans, implements, and evaluates the patient’s plan of care. Provides direct skilled nursing care and observes and instructs the patient in their place of residence. May coordinate services of other caregivers.

AREAS OF RESPONSIBILITIES

1. Provides services requiring substantial and specialized nursing skill, in accordance with the plan of

treatment signed by the physician and makes initial evaluation visits to clients with medical illnesses, chronic

diseases, behavioral health disorders, etc.

2. Identifies and distinguishes between physical and psycho-social signs and symptoms. Selects and performs

those therapeutic measures which are essential for effective execution of the nursing regimen for assigned

patients/clients.

3. Develops, implements and continuously evaluates the nursing regimen for assigned patients/clients. May

perform assessment of behavioral health needs, wound care, catheter insertion, medication teaching,

diabetic care, patient/family education and counseling and aseptic technique.

4. Completes comprehensive patient assessments and develops, prepares and maintains individualized client

care progress records, including required Outcome and Assessment Information Set (OASIS)

documentation.

5. Records and maintains nursing care plans and progress notes on patients/clients to ensure continuity of

care and initiates, develops and implements revisions as needed.

6. Interprets and reports responses of patients/clients to appropriate members of the health team and makes

referrals to other disciplines in collaboration with physician, client and family, as appropriate.

7. Maintains continuity of client care by liaising with other health professionals assigned to the client including

reporting signs, symptoms and changes to the patient’s condition to appropriate parties.

8. Provides teaching, guidance and direction to allied nursing personnel in rendering patient care.

9. Participates in departmental and interdisciplinary conferences pertaining to policies and procedures affecting

nursing practice.

10. Interprets philosophy and objectives of agency and Nursing Department to patients/clients, families and

other groups.

11. Maintains professional competence through participation in continuing education and other appropriate

learning experiences, including agency provided in-service programs.

12. Participates in internal/external quality assurance/performance improvement (QA/PI) activities, programs,

and training, as required.

13. Performs other professional nursing activities and related duties, as delegated by nursing service

administration, including clinical record reviews.

14. Provides individualized skilled nursing care to the patients requiring part-time intermittent professional

nursing service through the use of the nursing process.

15. Provides assessment of patient and develops a plan of treatment and care with ongoing evaluation of

patient/family needs for other services.

16. Provides professional nursing services as outlined in the patient's plan of treatment and authorized by

patient's physician, and provides emergency treatment as needed.

17. Records physical, social, psychosocial and environmental needs of the patient. Provide ongoing monitoring

of the patient in the home care setting and escalates any clinical changes to the physician or non-physician

provider as needed.

18. Utilizes input from patient, caregiver, MD and peers to devise a Nursing Care Plan which is feasible within

the physical, financial and emotional resources of the patient/caregiver and the Department of Health

regulations.

19. Evaluates patient's response to plan of care as necessary, consistent with physician's orders.

20. Reviews and revises plan of care as necessary, consistent with physician's orders.

21. Plans activities necessary for effectuating the timely discharge/transfer of patient, and notifies all appropriate

parties including patient's physician.

22. Collaborates with case managers and other disciplines regarding the patient’s progress and discharge plans.

23. Demonstrates a professional attitude and ethical conduct in compliance with departmental standards.

24. Involves the patient and caregiver actively in goal setting.

25. Establishes and maintains a cooperative, effective working relationship with the staff, physician and nonphysician

providers, Case Managers and other hospital personnel, outside vendors, agencies and the

community at large.

26. Attends weekly to bi-monthly team meetings and participates in case conferences and case load reviews on

a weekly to bi-weekly basis.

27. When needed completes Physician’s Orders in a timely manner.

28. Completes admission paperwork, including OASIS, Physician and Nursing POCs and progress notes within

48 hours of visit encounter.

29. Reviews clinical records to ensure compliance with departmental and regulatory standards.

30. Obtains written orders for all verbal orders returned.

31. Maintain up-to-date patient files with complete records including care plans and re-certifications, reports of

all services rendered, progress notes and discharge summaries.

32. Writes clean and concise progress notes that reflect the implementation of the plan of care and the patient’s

response to that plan of care.

33. Competent in knowledge of patient teaching plans and interventions.

34. Competent in knowledge of safe administration and teaching medications.

35. Demonstrates safety and accuracy in performing treatments and procedures according to the Home Care

Department standards of care/practice.

36. Competent to complete thorough and accurate nursing assessments.

37. Demonstrate competence in skilled nursing interventions.

38. Competent in knowledge of documentation requirements for Home Care.

39. Participates in case conferences and/or Interdisciplinary Team conferences as needed and as designated by

the Clinical Manager.

40. Works with other members of the Interdisciplinary Team to develop appropriate interventions in order to

achieve clinical and functional goals.

41. Participates in the agency’s Quality Assurance Performance Improvement/PIP as assigned.

42. Supervises and monitors the care given by home health aides and ensures proper documentation.

43. Participates in an interdisciplinary health care team in determining and implementing a comprehensive plan

of care.

44. Participates in the coordination and supervision of other professional and para-professional services in the

home and provides supervision as needed and per DOH regulations.

45. Provides patient/family/significant other/patient identified representatives with teaching and involves them in

assessment activities and goal setting.

46. Maintains current, complete, and appropriate documentation in the patient care record. May be required to

use computer systems in carrying out these functions.

47. Duties include but may not be limited to wound care, including NPWT/VAC, Peg/Trach Care Management,

Foley insertion and catheter care management, JP/PleuRx Drain care, administering injections.

48. Provides teaching on disease and medication management.

49. Obtains photographs for consultation by wound specialists.

50. Ability to apply evidence-based practices to the home care setting.

51. And other duties as ordered/prescribed.

Minimum Qualifications

For individuals holding an unrestricted registered professional nursing license BEFORE July 1,
2020 in New York State, another state or United States territory:
1. A valid New York State license and current registration to practice as a Registered Professional Nurse
in New York State; and
2. Valid and current certification in Basic Life Support (BLS) through the American Heart
Association (AHA).

Ability to travel regularly to patient/client assignments across New York City via public transportation and/or private vehicle; and  Demonstrated commitment to continued professional development.

For individuals issued a registered professional nursing license on or AFTER July 1, 2020,
based on expected implementation of Chapter 502 of the Laws of 2017 and Chapter 380 of the
Laws of 2018:
1. A valid New York State license and current registration to practice as a Registered Professional
Nurse in New York State; and
a. A Bachelor’s of Science degree in Nursing or higher (or other nursing degree, as identified by NYS
Education Department including Master of Science in Nursing, Doctor of Nursing Practice, Doctor of
Philosophy Degree in Nursing or Doctor of Nursing Science) from an accredited college or
university, registered with the NYSED; or
b. Obtains a Bachelor’s of Science Degree in Nursing or higher, as described in “a” above, within ten
(10) years of the date of initial licensure; and
2. Valid and current certification in Basic Life Support (BLS) through the American Heart Association
(AHA).