Job Description

1. Provides individualized skilled Nursing care to the patients requiring part-time intermittent professional nursing service through the use of the nursing process.

2. Provides assessment of patient and develops a plan of treatment and care with ongoing evaluation of patient/family needs for other services.

3. Provides professional nursing services as outlined in the patient's plan of treatment and authorized by patient's physician, and provides emergency treatment as needed.

4. Records physical, social, psychosocial and environmental needs of the patient. Provide ongoing monitoring of the patient in the home care setting and escalates any clinical changes to the physician or non-physician provider as needed.

5. Utilizes input from patient, caregiver, MD and peers to devise a Nursing Care Plan which is feasible within the physical, financial and emotional resources of the patient/caregiver and the Department of Health regulations.

6. Evaluates patient's response to plan of care as necessary, consistent with physician's orders.

7. Reviews and revises plan of care as necessary, consistent with physician's orders.

8. Plans activities necessary for effectuating the timely discharge/transfer of patient, and notifies all appropriate parties including patient's physician.

9. Authorize & coordinate all services including nursing, rehab, respiratory therapy, nutritional services, equipment, professional and non-professional staffing and support services.

10. Collaborates with Accountable Care Managers and other disciplines regarding the patient’s progress, plan of care and discharge plans.

11. Demonstrates a professional attitude and ethical conduct in compliance with departmental standards.

12. Involves the patient and caregiver actively in goal setting

13. Establishes and maintains a cooperative, effective working relationship with the staff, MD’s, Case Managers and other hospital personnel, outside vendors, agencies and the community at large.

14. Attends weekly to bi-monthly team meetings and participates in case conferences and case load reviews on a weekly to bi-weekly basis.

15. When needed completes Physician’s Orders in a timely manner.

16. Completes admission paperwork, including physician and nursing POCs within 48 hours of visit encounter

17. Reviews clinical records to ensure compliance with departmental and regulatory standards.

18. Obtains written orders for all verbal orders returned.

19. Writes clean and concise progress notes that reflect the implementation of the plan of care and the patient’s response to that plan of care..

20. Maintain up-to-date patient files with complete records including care plans and re-certifications, reports of all services rendered, progress notes and discharge summaries.

21. Competent in knowledge of patient teaching plans and interventions

22. Competent in knowledge of safe administration and teaching medications.

23. Demonstrates safety and accuracy in performing treatments and procedures according to the Home Care Department standards of care/practice.

24. Competent to complete thorough and accurate nursing assessments.

25. Demonstrate competence in skilled nursing interventions.

26. Competent in knowledge of documentation requirements for Home Care.

27. Participates in case conferences and/or Interdisciplinary Team conferences as needed and as designated by the Clinical Manager

28. Works with other members of the Interdisciplinary Team (IDT) to develop appropriate interventions in order to achieve clinical and functional goals

29. Participates in the agency’s Quality Assurance Performance Improvement/PIP as assigned.

30. Supervises and monitors the care given by home health aides and ensures proper documentation.

31. Participates in an interdisciplinary health care team in determining and implementing a comprehensive plan of care.

32. Participates in the coordination of other professional and para-professional services in the home and provides supervision as needed.

33. Provides patient/family/significant other/patient identified representatives with teaching and involves them in assessment activities.

34. Maintains current, complete, and appropriate documentation in the patient care record. May be required to use computer systems in carrying out these functions.

35. Duties include but may not be limited to wound care, including NPWT/VAC, Peg/Trach Care Management, Foley insertion and catheter care management, JP/PleuRx Drain care, administering injections.

36. Provides teaching on disease and medication management.

37. Obtains photographs for consultation by wound specialists.

38. Ability