LPN/RN - Crisis Residential Unit

LPN/RN - Crisis Residential Unit This position will be located at our Crisis Residential Unit in Dothan, Al 12 HOUR PITMAN SCHEDULE 7PM-7AM WEEK I: TUESDAY, WEDNESDAY, SATURDAY, SUNDAY WEEK II: MONDAY, THURSDAY, FRIDAY POSITION SUMMARY/FUNCTION Provides medical nursing and laboratory testing services to consumers of Spectracare Health Systems at residential facilities for multiple treatment modalities. Gives nursing care to consumers under direct supervision of a physician and monitors consumer’s health during treatment program. ESSENTIAL DUTIES/RESPONSIBLITIES/FUNCTIONS/TASKS: 1. Performs medical information gathering services. Obtains all pertinent and historical consumer medical data in each instance of consumer admission into the facility. Establishes and updates those health records required for program operation. Performs certain medical laboratory tests such as TB (Mantoux) for consumers and staff. Other testing may include urinalysis, protein, blood sugar, hematocrit or hemoglobin, and VDRL. Reports and documents results of testing, highlighting irregularities and notifying physician/agencies as required. Observes consumers daily, converses with them and their counselors and records pertinent health information into electronic medical record. Reviews records with and reports physical status of consumers to the physician and/or program director when medically necessary or appropriate. Prepares schedule and necessary documentation for physician’s visit and assists physician and consumers as needed. 2. Provides physician, staff and others appropriate information concerning consumers. Informs consultant physician of new consumer’s admissions, health problems, etc. and obtains physician instructions and his signature on operational medical forms and records. Provides medical health education to include information on treatment, medications, and specific diet plans. Provides health education and information about addictions, medical aspects, physical effects of drugs and alcohol on the human body, HIV/AIDS, etc., to consumers, families, volunteers, visitors and others. Conducts or assists with staff-in-services as appropriate. Participates in case staffing, informing staff of consumer’s medical concerns or situations and monitoring the medical needs of the consumers. 3. Provides health needs to consumers. Monitors, assesses and attends consumer health needs and implements nursing approaches or medical treatments as prescribed by physician to alleviate problems. Exercise nursing skills and create procedures to manage certain consumer physical requirements, i.e. Cardiac/ADA Diet, lifting restrictions, etc. Remains available to consult with consumers who report illness or become ill and initiates appropriate nursing measure and /or notifies physician of signs or symptoms. Administers medical treatment to consumers as instructed and authorized by the physician or arranges for consumer transport to a local hospital for treatment. Administer IM psychotropic injections. Keep an accurate check on ordered lab work notifying psychiatrist of abnormal lab values. Maintain emergency medication kit. Provide mental health consultations with other agencies. Coordinate efforts to maintain recent medical treatment from other medical agencies. Obtain medical equipment as prescribed by physician for consumers. Assist with activities of daily living as needed by consumers. May be required to pick up medications and/or transport clients via SpectraCare vehicles 4. Performs Standard Universal Procedures. TB Tine tests for all new employees that have not been tested within one year as well as yearly Tine tests, if needed. Appropriate assessment of employees and consumers that have tested positive. Administer Hepatitis B vaccine to new employees, as needed. Perform every six months Universal Precautions checklist at designated times. Perform other responsibilities as directed by Supervisor, including but not limited to: A. Obtains, stores securely and administers all drugs and medications according to regulatory laws, SpectraCare procedures, physician’s instructions, DMH Nurse Delegation Program standards and professional nursing standards. Keeps accurate records of all drug and medication transactions and usage. B. May occasionally be required to be “on-call”. C. Treat clients with respect and courtesy at all times. D. Provide coverage during crisis moments with or without notice. E. Responds to crisis situations that may arise within the home and/or with clients. F. Ensure necessary documentation is completed in a timely manner with minimal errors and in compliance with applicable guidelines and policies. G. Receive and respond to inquiries promptly and courteously. H. Meet with supervisor as established. I. Follow guidelines of SpectraCare Personnel Policy, SpectraCare Clinical Policy, including but not limited to the Alabama Administrative Code, CMS, and all other applicable regulating and contractual entities. J. Participate in training, workshops, in-services, and/or administrative meetings as assigned. K. Ensure any necessary documentation is completed and up to date before annual leave or personal leave is taken. L. Adhere to Dress Code as set forth in the SpectraCare policies and procedures. M. Functions and performs well in stressful environments and manages work related stress to ensure the safety of others. N. Demonstrates a willingness to work on any unit / program at SpectraCare based on facility needs as directed. O. Ability to conform to SpectraCare’s Core Values as duties are carried out daily. P. Functions within professional boundaries with individuals and others. Q. Works in a cooperative manner with other SpectraCare employees, individuals, and/or family members. R. Performs duties independently and/or with minimal supervision. S. Perform all duties with the highest standard of ethics. T. Works well with other staff and individuals to ensure safety of program, individuals and other staff. U. Other services, tasks, functions, and responsibilities deemed necessary; not otherwise specified. 6. Assist with maintaining consumer’s record in a professional manner and in accordance with all standards including but not limited to SpectraCare Policy and Procedure, Alabama Administrative Code, Alabama Board of Nursing, CMS, and all other applicable regulating and contractual entities. Scheduling billing and appointments in EMR for nursing notes, interventions, and physician appointments. Maintain medical and psychiatric physician notes in EMR on the day service is provided. C. Progress notes are completed on the day service is provided. D. Progress notes are written in a professional manner utilizing appropriate medical terminology and meeting all imposed standards. E. Service logs are completed the day the service is provided and turned into designated secretary. F. Service logs are accurate and reflect appropriate service being provided. 7. Regular attendance with timely arrival and departure according to scheduled hours. Must be able to work full time with rotating assignments as necessary to include but not limited to overtime hours, nights and/or weekends as scheduled. To ensure client safety while on duty, must remain awake during scheduled working hours. 8. Assist with the Nurse Delegation program complying with standards as set forth by Alabama Board of Nursing and Alabama Department of Mental Health. A. Become fully accredited as a MAS certified nurse and obtain certification as needed. B. Demonstrate willingness to allow MAC workers to operate under the BON license. C. Provide initial and on-going training for MAC workers completing documentation as required (certificates, skills check list, grade tests, etc.). D. Supervise MAC workers on all medication issues whether in person/via phone/email or other means. E. Assess to determine if client can self-medicate and reassess yearly or as needed before annual reassessment. F. Reassess MAC workers on an annual basis and recommend certification or decertification, completing documentation as required. G. Recommend decertification of MAC worker if a level 3 error occurs or if RN/LPN assesses and finds skills lacking. H. Attend trainings concerning NDP. I. Assist other MAS and/or MATT Nurses in duties under NDP. J. Perform nursing assessments upon client admission into the program and reassess annually or as needed. NON-ESSENTIAL DUTIES/RESPONSIBLITIES/FUNCTIONS/TASKS: Attend departmental meetings and other assigned meetings. Attend all required job-related training. Assist in other areas as needed. Conform to SpectraCare’s policies and procedures. Take part in continuing in-service training and participates in activities to promote professional development. ESSENTIAL QUALIFICATIONS/KNOWLEDGE/SKILLS/ABILITIES: Thorough knowledge of psychotropic medications and mental illness diagnosis Maintain medical and psychiatric physician notes, interventions, etc in EMR. Ability to respond professionally in a crisis situation. Clinical knowledge of Mental Illness and Substance Use and their social implications. Ability to understand recordkeeping requirements of SpectraCare Policy and Procedure, Alabama Board of Nursing, Alabama Administrative Code, CMS, and other applicable regulating and contractual entities. Ability to communicate with mental illness/substance use clients as well as all levels of organizational staff in a professional manner, both written and oral. Ability to use discretion, independent action and judgment as it relates to nursing skills. Knowledge and understanding of crisis intervention techniques. Ability to have patience and emotional stability. Must perform all duties with the highest standard of ethics. Knowledge of business English, spelling and arithmetic. Knowledge of office practices and procedures. Ability to operate office machines such as computer, fax machine, and copy machine. Ability to read instruction manuals printed in English. Ability to understand and follow oral and written instructions. Ability to perform a wide variety of job tasks, in a safe manner without endangering any employee, client, or asset. Ability to follow through with assignments with minimal supervision. Ability to follow orders and directives and work with supervisor and other staff. Ability to adhere to SpectraCare policy, HIPAA laws, and 42 CFR regarding confidentiality. Ability to maintain unit files through electronic medical record. Ability to adhere to health and safety standards. Ability to stay awake during working shift. Basic knowledge of individual’s rights. Ability to demonstrate initiative. Ability to travel as necessary. Ability to function and perform well in stressful environments and manage work related stress to ensure safety of those in the program. Ability to pass a drug screen when given to include but not limited to pre-employment, random, post-accident, suspicion, etc. Ability to function within professional boundaries with individuals and others. Ability to adapt to conditions which may vary considerably. Ability to relay coping skills, positive attitude skills and self-esteem. Ability to facilitate educational groups to individuals in the program. Ability to establish effective working relationships with other staff, Program Director and all levels of organizational staff. ESSENTIAL TRAINING REQUIREMENTS: Complete initial new hire training. Complete required on the job training (OJT) training by the department. Obtain proper certifications needed to perform job duties. Complete annual training as required by the Alabama Administrative Code, CMS, and all other applicable regulating and contractual entities. Complete First Aid/CPR upon hire and prior to working alone with clients; and continuously thereafter maintaining current certification. WORK ENVIRONNMENT / PHYSICAL REQUIREMENTS: Physical ability to work assigned shift. May require periodic…