Completes initial and ongoing assessments to identify the physical, psychosocial, and environmental needs of home health patients. Completes assessments at appropriate time points, including Outcome and Assessment Information Set (OASIS), or other assessments as appropriate to the patient. Regularly reevaluates the patient's nursing needs and evaluates the outcomes of care. Develops, initiates, and revises the plan of care in partnership with the patient, representative (if any), and caregiver(s) as necessary to ensure quality and continuity of care. Initiates appropriate preventive and rehabilitative nursing procedures. Refers to other services as needed. Provides patient and caregiver education. Plans for the discharge of the patient from services. Furnishes those services requiring substantial and specialized nursing skill that are ordered by the physician as indicated in the plan of care. Counsels the patient, caregiver, and family in meeting nursing and related needs. Uses infection control measures that protect both the staff and the patient. Coordinates services. Informs the physician and other personnel of changes in the patient's condition and needs. Communicates with all physicians involved in the plan of care and other health care practitioners related to the current plan of care. Integrates orders from all relevant physicians involved in the plan of care and ensures the orders are approved by the responsible physician. Monitors assigned cases to ensure compliance with requirements of third-party payors. Prepares clinical and progress notes. Completes appropriate documentation in a timely manner. Demonstrates commitment and professional growth by participating in the Agency sponsored in-service programs and maintaining or improving competency. Participates in the Agency’s QAPI program. Supervises, teaches, and provides clinical direction to other nursing personnel. Assigns home health aides to specific patients. Supervises LPNs/LVNs and paraprofessionals providing services to patients. May conduct aide competency evaluations if qualified with two years of clinical experience and one year of home health experience. Promotes the Agency’s philosophy and administrative policies. Performs on-call responsibilities and provides on-call services to patients and their families as assigned. Provides effective communication to patients, family, team members, and other healthcare professionals

Education: Graduate from an accredited diploma, associate, or baccalaureate nursing program.

Licensure: Active, state license as a registered nurse, or a multi-state license issued by a Nurse Licensure Compact (NLC) member state.

Current driver’s license.

Experience: One year of experience as a registered nurse in a clinical care setting. Home health experience preferred.

Skills: Nursing skills as defined as generally accepted standards of practice. Good interpersonal skills.

Proof of current CPR certification.

Transportation: Reliable transportation and valid auto liability insurance.

Environmental and Working Conditions: Works in patients’ homes in various conditions; possible exposure to blood, bodily fluids, and infectious diseases; ability to work a flexible schedule; ability to travel locally; some exposure to unpleasant weather; PRN emergency calls.

Physical and Mental Effort: Prolonged standing and walking required, with ability to lift up to 50 pounds and move patients. Requires working under some stressful conditions to meet deadlines and patient needs, and to make quick decisions and resource acquisition; meet patient and family individualized psychosocial needs. Requires hand-eye coordination and manual dexterity.