Overview

To manage and coordinate the care of assigned clients in the homes of clients byproviding comprehensive skilled nursing services and referral for therapeutic services as needed in order toachieve maximum rehabilitation and recovery for the Agency's clients.

Responsibilities

 Completes initial and periodic comprehensive assessments of clients, caregivers, and homeenvironments for admission to and continued service from the Agency to determine needs, effectivenessof care provided, and achievement of anticipated outcomes. Assessments may include OASIS items atappropriate time points. Accepts client admissions as assigned by Agency and weekend on-call assignments. Provides comprehensive nursing care through the utilization of the home assessment, nursing diagnoses,and physician-approved care plans. Performs treatment(s) requiring specialized skills ordered by the physician. Observes signs and symptoms and report them to the VP of Clinical Services / Director of ProfessionalServices and/or physician as appropriate. Notes changes in physical or emotional status of clients. Assesses nutritional needs and diet of clients as ordered by physician. Counsels, teaches, and supervises the client and caregivers regarding self-care techniques, nursing careneeds, the disease process, and promotion of health and disease prevention strategies. Promotes client and caregiver independence in self-care. Initiates appropriate preventive and rehabilitative nursing procedures. Involves other Agency staff in the care of clients under the direction of a physician when deemedhelpful to client rehabilitation. Coordinates services among Agency staff and appropriate community services to ensure achievement ofclient care goals. Establishes priorities and goals for the client and initiates and revises the plan of care to achieve thosegoals. Administers medications and treatments as prescribed by a physician. Maintains comprehensive medication and administrative records. Provides supervisory visits for assigned home health aides at least every 14 days and documents visit inclinical records.

 Consults with physician when necessary and document in writing appropriate changes of orders wherenecessary Serves as advocate for clients and report changes in client needs to the Agency and physician. Requests increases or reductions in service as determined by client needs. Participates in professional meetings and in-services when directed. Arranges necessary referral to community agencies in collaboration with other staff disciplines asindicated. Develops and implements discharge plans with clients and/or caregivers. Prepares written care plans for Paraprofessional staff, maintains communication with Paraprofessionalstaff regarding changes in client condition or plan of care, and evaluates. Utilizes electronic documentation of client care and complies with Agency policy regarding timelinessin submission of documentation. Supervises Licensed Practical Nurses as required and documents supervisory visits in clinical records atleast monthly. Keeps informed of legislative requirements, current charting needs, and dates for recertification forassigned clients. Fulfills other assignments as requested by the VP of Clinical Services or Director of ProfessionalServices.

Qualifications

 Holds a current Registered Nurse license Is a graduate from an approved school of nursing. Has a minimum of two years of experience in an acute setting that requires heart, lung, and physicalassessments or has demonstrated ability or education in same areas. Has current CPR certification. Has excellent communication, organizational, and human relations skills. Is able to function with minimal supervision. Is able to manage multiple projects/changing priorities. Is able to employ critical thinking skills.