Home Health Registered Nurse

Provides coordinated skilled nursing care to patients of all age groups, on an intermittent basis in the home.

Demonstrates accountability and responsibility in collaborating with the interdisciplinary team to establish and achieve patient goals and maintain high quality patient care. Performs in accordance with physician’s orders and under the supervision of the Home Health Director.

Essential Functions

• Assesses home health patients identifying physical, psychosocial and environmental needs as evidenced by documentation, clinical records, case conferences, team reports, call-in logs and on-site evaluations.

• Completes OASIS, assessment and visit paperwork according to agency policy. Assures clinical notes accurately indicate continuing communication and coordination of services with the physician, other interdisciplinary team members and patient/family/caregiver.

• Communicates significant findings, problems and changes to Home Health Director and physician, and documents all findings, communications, and appropriate interventions.

• Demonstrates knowledge and proficiency in identifying, reporting and documenting problems, adverse reactions or possible complications related to patient care. Recognizes and reports life threatening situations and responds appropriately. Recommends and incorporates other disciplines in the care of the patient, as needed, and under the direction of the referring physician.

• Participates in the development and implementation of the Plan of Care (POC) to ensure quality and continuity of care and appropriate discharge planning. Establishes Plan of Care in coordination with the physician, patient, family and interdisciplinary team members. Incorporates long and short term goals established in the Plan of Care into nursing care, as evidenced by documentation in visit notes.

• Supervises and provides clinical direction to home health aides and LPNs/LVNs to ensure quality and continuity of services provided.

• Participates in interdisciplinary patient care conferences and Agency Performance Improvement processes.

• Receives referrals from physicians, hospitals, clinics, patients, families and other agencies when needed and notifies agency personnel on a timely basis.

• Assures the continuity of patient care and coordination of services through delivery of quality patient care. Performs in a manner that is consistent with current standards of practice and with the Agency’s policies and procedures. Follows all infection control and universal precautions guidelines/standards per agency policy.

• Responsible for participating in on-call rotation and emergency call according to agency policy.

• Demonstrates commitment, professional growth and competency. Strives to continually improve nursing knowledge base through individual research, reading, attendance at workshops/professional conferences and professional organizations.

This job description represents an overview of the responsibilities for the above referenced position. It is not intended to represent a comprehensive list of responsibilities. Colleagues should perform all duties as assigned by his her supervisor.

Education and Experience

Graduate of an accredited school of nursing. Current license as a Registered Nurse in good standing for the state.

BSN preferred. One year experience as a registered nurse in a clinical setting required. Acute care and home care experience are preferred.

Certifications, Licenses, and other Special Requirements

Maintains Continuing Education Units for licensure renewal, as applicable to state regulations. Reliable transportation and proof of valid automobile liability insurance. Must have valid driver’s license. Current BCLS

Certification prior to providing patient care. Bilingual and able to read, write and speak Spanish proficiently preferred.

Physical Demands and Working Conditions

• Must be able to travel in a vehicle numerous hours/miles per day, visiting up to but not limited to 1-10 homes a day, to deliver personal care to patients. Clinicians are not assigned to any one specific geography and areas of travel may vary and are subject to change.

• Environmental status of patient homes and dwellings where care is delivered is variable and unpredictable.

• Must be able to climb stairs and gain access to a variety of different dwellings to deliver care, to include in various inclement weather conditions such as rain, snow and ice.

• Must be able to type on a tablet/laptop computer keyboard for medical record data entry associated with each patient visit.

Management/Decision Making

Uses limited independent judgment to make decisions based on precedents and established guidelines. Solves problems using standard procedures and precedents. Knows when to refer issues to supervisor and when to handle them personally.

Knowledge and Skills

Has a working knowledge of a skill or discipline that requires basic analytic ability. Has an overall understanding of the work environment and process. Has working knowledge of the organization.

Expresses verbal and writtencommunication in a clear, positive and cooperative manner. Ability to maintain privacy and confidentiality with regard to patient, staff and agency information. Identifies and resolves problems in a timely manner.

Ability to prioritize and plan work activities. Possesses the ability to make independent decisions when circumstances warrant such action. Demonstrates an interest in working with a senior population.

Ability to establish an effective working relationship with all departments and the community. Excellent organizational and follow-through skills.