Assesses assigned case load of home health care patients to identify the physical, psychosocial and environmental needs of patients as evidenced by documentation, clinical records, case conferences, team report, call-in logs, and on-site evaluations. Meets all regulatory and accreditation requirements related to following the Plan of Care.
Makes the initial evaluation and re-evaluates the patients nursing needs during each visit. Makes follow up assessments according to OASIS and PPS regulatory guidelines.
Communicates significant findings, problems, and changes in condition or environment to the clinical supervisor, the physician and/or other personnel involved with patient care.
Reports unsafe condition to the appropriate Clinical Supervisor and physician in a timely manner.
Implements the plan for patient safety, using the patient, family, and community resources.
Participates in the implementation of the plan of care of an assigned case load to ensure quality, continuity of care, and achievement of patient outcomes.
Demonstrates competency in all levels of home health nursing practice.
Identifies deviations from normal Nursing and normal patient condition status. Initiates appropriate actions based on the deviation.
Verifies the plan of care prior to each visit and provides care according to physician’s orders, assessment data, Plan of Care and established standards and guidelines.
Makes revisions to the plan of care in response to identified patient care issues and notifies the Clinical Supervisor
Writes physician orders to cover additional visits and changes to the plan of care.
Incorporates patient care goals established in the plan of care, into nursing care, as evidenced by documentation in nurses note.
Provides those services ordered requiring substantial and specialized nursing skill.
Follows appropriate preventative and rehabilitative nursing procedures according to the plan of care.
Documents medication regimen and updates medication profile according to established procedures.
Counsels, instructs and includes the patient and family in following the Plan of Care and meeting nursing and related needs.
Follows all infection control guidelines and standards per Agency policy
Supervises and provides clinical direction to the Licensed Practical Nurse & the Home Health Aide to ensure quality and continuity of services provided.
- Compares the Home Health Aide care plan to the actual care given as verified with patient/care-giver. Supervises & documents on the visit note and reports any discrepancies of the home health aide to the Clinical Supervisor.
Instructs and evaluates the Licensed Practical Nurse & the Home Health Aide with special patient care procedures in accordance with the scope of practice and home health care policies of the agency.
Communicates care coordination & changes to the appropriate team members as they occur to the patient’s plan of care.
Promotes compliance with all fiscal intermediary and/or other third party payers, through education, coaching, and other assistance as necessary.
Maintains current knowledge of, and promotes compliance with all federal, state and local regulations.
Keeps fully cognizant of current Medicare, Medicaid, and third-party reimbursement regulations and changes and ensures compliance.
Assures the continuity of quality patient care delivered.
Maintains communication with Clinical Supervisor providing updates and changes in schedules, patient data or needs, physician orders or special instructions.
Participates or communicates in patient care conferences offering clinical suggestions and updates of patient’s progress towards goals.
Assures clinical notes indicate continuing communication and coordination of services with physician, other staff and disciplines.
Demonstrates effective time management skills by completing patient assignment within projected time frame and arriving to appointments on schedule.
Monitors assigned cases to ensure compliance with requirements of third party payor.
Ensures that all assessment nursing notes, supply sheets and visit logs are accurate, timely and turned into office according to office policy.
Demonstrates knowledge of current status of requirements of third party payer, by identifying and reporting potential payment/coverage problems to the appropriate clinical supervisor. (This includes but is not limited to Medicare, Blue Cross/Blue Shield, Medicaid and other 3rd party companies.)
Demonstrates commitment and professional growth.
Attends all required in-service programs within the review year as assigned by management. Independently obtains CEU’s as required by licensure and provides a copy of same to human resources
Promotes the Agency philosophy, mission statement and administrative policies to ensure quality of care.
Maintains patient & staff privacy and confidentiality at all times pursuant to HIPAA Privacy Final Rule.
Provides positive, supportive communication to physicians, patients, families, visitors, and other agency personnel.
Maintains availability by phone as directed by company policy.
Promotes Agency image by adhering to the dress code.
Reports to work as scheduled.
Reports to work and patient homes promptly as directed.
Handles the personal property of patients and their families with care.
Follows all infection control guidelines and standards per Agency policy.
Meets minimum productivity requirements based on agency standard.
Abides by company policy and procedures as outlined by company policy manual.
Performs other duties as assigned by the Supervisor.