1. Provides services in accordance with the plan of care.

2. Makes the initial evaluation visit, determines the immediate care and support needs of the patient, assesses eligibility and homebound status and develops the plan of care in coordination with other IDT members.

3. Regularly reevaluates the patients nursing needs and revises the care plan to meet the patients’ needs.

4.Initiates the plan of care and necessary revisions.

5.Furnishes those services requiring substantial specialized nursing skill.

6.Initiates appropriate preventive and rehabilitative nursing procedures.

7. Prepares clinical and progress notes for each patient visit and summaries of care conferences on patients in a timely manner as per Agency policy.

8. Coordinates services with other members of the IDT, all physicians involved in the patient care, other care providers, patient, representative and caregivers when appropriate.

9. Informs physician and other personnel of changes in the patient’s condition and needs.

10. Counsels the patient and family/significant others in meeting nursing related needs.

11. Participates in in-service programs, supervising and teaching other nursing personnel.

12. Understands and adheres to established Agency policies and procedures.

13. Processes orders and notifies physician of patient needs and changes in condition. Completes certification/recertification orders and discharge summaries.

14. Determines the amount and type of nursing needed by each individual patient.

15. Refers to Physical Therapist, Speech Language Pathologist, Occupational Therapist and Medical Social Worker those patients requiring their specialized skills.

16. Supervises the LPN/LVN every 30-days and supervises the HHA/CNA every 14-days (or per regulatory requirements) and teaches other nursing personnel.

17. Assigns home health aides to specific patients with written patient care instructions.

18. Conducts patient care conferences on patients assigned to his/her care.

19. Participates in peer review and quality management as assigned.

20. Participates in utilization review of medical records as assigned.

21. Gives total patient care as needed.

22. Takes on-call duty nights, weekends and holidays as assigned.

23. Completes and submits OASIS assessments, reassessments, and transfers, resumptions of care, discharges and significant change in condition in accordance with Agency defined time frames.

24. Appropriately utilizes ICD-10 diagnoses and codes.

25. Observes confidentiality, safeguards all patient related information.

26.Attends staff meetings and patient care conferences as scheduled.

27. Completes documentation and paperwork in a timely manner per Agency policy.

28. Immediately reports to Administrator/Clinical Manager any patient incidents/variances or complaints.

29. Demonstrates competent performance of technical skills according to established procedures.

30. Understands and adheres to established policies and procedures.

31. Adheres to Agency standards and consistently interprets and accurately performs all assigned responsibilities.

32. Maintains acceptable attendance status, per Agency policy.

33. Reports all incomplete work assignments to Clinical Manager.

34. Appearance is always within Agency standard; is clean and well-groomed.

35. Demonstrates effective time management skills through daily documentation and infrequent overtime for routine assignments.

36. Maintains clean and neat work environment.

37. Demonstrates sound judgment, critical thinking and decision making.

38. Maintains current CPR certification.

39. Performs other duties as assigned.