A Registered Nurse (RN) administers skilled nursing care to patients on an
intermittent basis in their place of residence. This is performed in
accordance with physician orders and the plan of care per state Practice Act.
In this role, you will report to the Director of Nursing (DON).Duties/Responsibilities:
Develops, delivers/implements, revises, and evaluates individualized
patient-centered care plans under the supervision of a physicianProvides case management to an assigned group of patients and ancillary staffUnderstands and submits required data collection sets (OASIS, PAR,
etc.) and other documentation as requested by the state and/or federal
government and insurance payers within required timeframesMakes the initial evaluation visit and regularly reevaluates the patient's
nursing needs per state and payor requirementsActs as an advocate for patient welfare and coordinates care between
patients, their families/caregivers and/or their authorized
representative, the agency and other healthcare
providers/facilities/outside agenciesFurnishes those services requiring substantial specialized nursing skill
according to competency levelDemonstrates problem solving abilities and positive interpersonal
communication skillsIdentifies care preferences of patients and verifies that interventions meet
the patient's needs and their goals of treatmentInitiates appropriate preventive and rehabilitative nursing proceduresPrepares clinical and progress notes for each patient visit and summariesAttends case conferences as assignedInforms physician and other personnel of changes in the patient's condition
and needsCounsels the patient and family/significant others in meeting nursing and
related needs. Educates on the proper home health strategies and procedures
utilizing community resources as applicableObserves and reports patient symptoms, reaction to treatments, drugs and
changes in the patient's physical or emotional condition, responsible for
medication reconciliationParticipates in in-service programs, supervising and teaching other nursing
personnel as assignedAdministers medication per agency policy and physician ordersProvides written instructions for aides or other ancillary disciplines caring
for the patientProcesses orders and notifies physician of patient needs and changes in
conditionRefers cases with physician's orders to Physical Therapist, Speech
Language Pathologist, Occupational Therapist and Medical Social Worker for
those patients requiring their specialized skillsUnderstands and adheres to the Policy/Procedure, Best Practices,
Infection Control Plan, EMS Plan and the Compliance PlanParticipates in clinical record/utilization review of medical records and
quality assurance and performance improvement (QAPI) quarterly and as
assigned. Reports/records all applicable infections, occurrences, and
complaintSubmits documentation within 24 hours or per state requirementsMaintains confidentiality of patient, employee, and agency mattersTakes on-call duty nights, weekends, and holidays, as assigned. When
functioning as the on-call RN acts as the after-hours supervising nurse and
makes nursing assessment and triage decisions under the guidance of the
overall Clinical Supervisor as applicableImmediately reports to Nursing Supervisor any patient incidents/variances or
complaintsDemonstrates competent performance of technical skills according to
established proceduresMaintains acceptable attendance status, per Agency policyReports all incomplete work assignments to Nursing SupervisorDemonstrates effective time management skills through daily documentation and
infrequent overtime for routine assignmentsEnsures that the following information/instruction is given in writing to
the patient/caregiver/representative: Visit schedule with frequency of
visits, complete Medication Profile any treatments to be administered by
agency staff (POC), any other pertinent instruction related to the
patient's care needs, and name and contact information of the agency's
Clinical