DUTIES 

To provide nursing care in accordance with the patient's plan of care to include comprehensive health and psychosocial evaluation, monitoring of the patient’s condition, health promotion and prevention coordination of services, teaching and training activities and direct nursing care.

RESPONSIBILITIES

Coordinates total patient care by conducting comprehensive health and psychosocial evaluation, monitoring the patient's condition, promoting sound preventive practices, coordinating services and teaching and training activities.

Evaluates the effectiveness of nursing service to the patient and family on an ongoing basis.

Performs admission, transfer, and re-certification, resumption of care and discharge OASIS for the home care patient.

Prepares and presents patient's record to the Clinical Record Review Committee as indicated.

Consult with the attending physician concerning alterations of Patient Care Plans, checks with the appropriate supervisor and makes changes, as appropriate.

Coordinates patient services.

Submits clinical notes no less often than weekly and progress notes and other clinical record forms outlining the services rendered as indicated.

Submits a tally of patient care visits made each day.

Participates in case conferences, discuss with the supervisor problems concerning the patients and how they may best be handled.

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.

Obtains orders for paraprofessional service and submits a referral to the appropriate personnel.

Participates in the patient’s discharge planning process.

Cooperates with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive care plan.

Participates in staff development meeting.

Continually strive 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.

Participates in the development and periodic revision of the physician's Plan of Treatment and processes change orders as needed.

Submits clinical notes weekly, and progress notes and other clinical record forms outlining the services rendered.

Participates in the patient’s discharge planning process.

Maintains an on-going knowledge of current drug therapy.

Adheres to Federal, state and accreditation requirements including Medicare and Medicaid regulations.

May be requested by Director of Nursing to fill in for the other nurses.

COORDINATES THE ADMISSION OF A PATIENT TO THE AGENCY

Conducts an initial and ongoing comprehensive assessment of the patient’s needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points.

Obtains a medical history from the patient and/or a family member particularly as it relates to the present condition. 

Conducts a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet, etc.

Evaluates the patient, family member(s) and home situation to determine what health teaching will be required.

Evaluates the patient's environment to determine what assistance will be available from family members in caring for the patient.

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.

Explains nursing and other Agency services to patients and families as a part of planning for care.

Develops and implements the nursing care plan.

May be requested by the Director of Nursing to fill in for other nurses who are on vacation or sick.

PROVIDES SKILLED NURSING CARE AS OUTLINED IN THE NURSING CARE PLAN 

Nursing services, treatments and preventative procedures requiring substantial specialized skill and ordered by the physician.

The initiation of preventative and rehabilitative nursing procedures as appropriate for the patient's care and safety.

Observing signs and symptoms and reporting to the physician reactions to treatments, including drugs, as well as changes in the patient's physical or emotional condition.

Teaching, supervising and counseling the patient and caregivers regarding the nursing care needs and other related problems of the patient at home.

ASSUMES RESPONIBILITY FOR THE CARE GIVEN BY THE HOME HEALTH AIDE

Supervises and evaluates the care given by the Home Health Aide as needed, and at a minimum of once every two weeks.

Submits to the appropriate department/individual written evaluations of the Home Health Aides who are providing service to the patients in his/her geographical area.

Participates in periodic conferences with the Home Health Aide supervisor concerning the Aide's performance.

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.

Evaluates the effectiveness of her nursing service to the individual and family.

Consults with the attending physician concerning alteration of the plan of treatment in consultation with the supervisor.

Submits clinical notes no less often than weekly and progress notes and other clinical record forms outlining the services rendered as indicated.

Submit a tally of visits made each day.

Participate in case conferences.

Discusses with the supervisor problems concerning the patients and possible resolution.

Discusses with the supervisor the need for involvement of other members of the health team such as the home health aide, physical therapist, speech therapist, occupational therapist, social worker, etc.

Obtains orders for paraprofessional service and submits referral to appropriate personnel.

Provide guidance and supervision to the LPN and supervises the LPN once monthly.

Coordinates total patient care.

Cooperates with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive care plan.

Participates in staff development meetings.

Participates in the educational experiences for student nurses.

Continually strives to improve his/her nursing care by attending in-service education, through formal education, attendance at workshops, conferences, goal setting, active participation in professional and related organizations and individual research and reading.

Participates in the planning, operation and evaluation of the nursing service.

Participates in the development and periodic revision of the physician’s Plan of Treatment and processes change orders as needed.

Participates in the patient’s discharge planning.

Submits clinical notes no less often than weekly, and progress notes and other clinical record forms outlining the services rendered as indicated.

Maintains an on-going knowledge of current drug therapy.

Prepare the care plan for the Home Health Aide.

JOB CONDITIONS

Must have a driver’s license and be willing and able to drive to patient’s residences.

The ability to access patients’ 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 patient's condition and to perform and demonstrate patient care.

Physical activities will include, walking, sitting, stooping, and standing and minimal to maximum lifting of patients and the turning of patients.

The ability to communicate both verbally and in writing in English is required as frequent communication by telephone and in writing is involved.

EQUIPMENT OPERATION

Thermometer, B/P cuff, glucometer, penlight, hand washing materials.

COMPANY INFORMATION

Has access to all patient medical records, personnel records and patient financial accounts which may be discussed with the Director of Nursing.

QUALIFICATIONS

1. Must be a graduate from an accredited School of Nursing.

1. Must be licensed in Pennsylvania as a Registered Nurse.

1. One or more years of experience in community/home health agency or in a hospital setting is preferred.

1. Must have knowledge of Medicare and Medicaid guidelines.

1. Must have a working knowledge of home health care and the principles and techniques of professional nursing and required documentation that pertains to it.

1. Should be skillful in organization and in the principles of time management and have knowledge of management processes.

1. Must be able to contribute to the quality of care being rendered through constructive communication with nursing managers and staff.

1. Must have a criminal background check.

1. Must have a current CPR certification. Online certification is not accepted.