Primary functions are to administer skilled nursing care for patients/clients of all ages in their place of residence, coordinate care with the interdisciplinary team, patients/clients and their families, and a referring agency. Assumes the responsibility for and participates in the coordination of care.

Responsibilities

Completes initial and ongoing assessments to identify the physical, psychosocial, and environmental needs of home health patients/clients . Completes assessments at appropriate time points, including Outcome and Assessment Information Set (OASIS) or other assessments as appropriate to the patient/client.

Regularly re-evaluates the patient's/client’s nursing needs and evaluates the outcomes of care.

Develops, initiates, and revises the plan of care in partnership with the patient/client, 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/client and caregiver education. Plans for the discharge of the patient/client 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/client, caregiver and family in meeting nursing and related needs. Uses infection control measures that protect both the staff and the patient/client.

Coordinates services. Informs the physician and other personnel of changes in the patient's/client’s condition and needs. Communicates with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care. Integrates orders from all relevant physicians involved into 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 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/clients. Supervises LPNs/LVNs and paraprofessionals providing services to patients/clients. May conduct aide competency evaluations if qualified with two years of clinical experience and one year of home health experience.

Provides effective communication to patients/clients, their family members, team members, and other health care professionals.

Performs on-call responsibilities and provides on-call services to patients/clients and their families as assigned.