Essential Functions:

1. Performs case assessments and participates in the development and maintenance of treatment/care plans.
   • Initiates and updates physician's plan of treatment.
   • Develops, implements, updates, and communicates patient plans of care every 60 days.
   • Orders, interprets, and evaluates diagnostic tests to identify and assess patient's condition.
   • Completes nursing assessments and certifies in writing for physician and payor source that patient meets criteria for home care every 60 days.
   • Performs re-certification/discharge assessments when appropriate.
   • Provides information regarding patient rights, staff assignments, and plan of care to patients and/ or family members.
   • Involves patients and family members in developing and implementing the plan of care whenever possible.
2. Implements current nursing practice.
   • Assesses patient condition/ needs in every home health care visit.
   • Provides skilled nursing services to meet patient needs and changed conditions, including treatments, diagnostic, preventative, and rehabilitative procedures.
   • Monitors clinical interventions for compliance with the defined plan of care.
   • Transcribes, implements, and evaluates outcome of physician orders.
   • Reports reactions to treatments and drugs and changes in patient's physical and emotional condition to physician.
   • Maintains accurate and timely clinical notes and incorporates into clinical record weekly.
   • Implements appropriate infection control and safety measures and reports all hazards and accidents in a timely and accurate manner.
   • Maintains confidentiality of patient information.
   • Teaches and advises patient and family members regarding patient's needs and other related problems of the patient at home.
3. Assists in the coordination of the provision of all home care services.
   • Conducts supervisory visits on Agency home health Aide's to evaluate their performance in skilled patient care.
   • Coordinates clinical activities of Agency home health Aides, LPN's, and related disciplines.
   • Communicates recommendations and requirements for continued/ discontinued or additional home healthcare services to appropriate individuals.
   • Participates in active case management.
   • Participates in on-call rotation as assigned.
   • Participates in development and revision of Agency clinical and administrative procedures as appropriate.
   • Promotes and maintains an Agency environment that is in compliance with federal, state, and local regulatory healthy and safety standards.
   • Responds to and communicates patient questions, concerns, and complaints in a timely and professional manner.
4. Uses equipment and supplies safely and efficiently.
   • Demonstrates accurate and efficient utilization of equipment and supplies.
   • Communicates information regarding malfunctioning equipment and/ or inadequate supplies to appropriate individuals.
   • Communicates information regarding safe and efficient use of equipment and supplies to patients and families.
   • Provides information about reimbursement of needed equipment and supplies to patients and families.
5. Participates in professional growth and development.
   • Participates in regular educational programs and Agency in-services.
   • Demonstrates current knowledge of the principles of nursing practice.
   • Demonstrates current knowledge of a coordinated interdisciplinary approach to the provision of home health services.
   • Participates in development and presentation of educational programs and in orientation/ training of other nursing personnel and home health aides as appropriate.
   • Maintains current professional licensure.
   • Participates in the Performance Improvement programs.
6. Fulfills additional performance responsibilities as assigned and necessary.