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.
the initial evaluation and re-evaluates the patients nursing needs
during each visit. Makes follow up assessments according to OASIS
and PPS regulatory guidelines.
significant findings, problems, and changes in condition or
environment to the clinical supervisor, the physician and/or other
personnel involved with patient care.
unsafe condition to the appropriate Clinical Supervisor and
physician in a timely manner.
the plan for patient safety, using the patient, family, and
in the implementation of the plan of care of an assigned case load
to ensure quality, continuity of care, and achievement of patient
competency in all levels of home health nursing
deviations from normal Nursing and normal patient condition status.
Initiates appropriate actions based on the deviation.
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.
revisions to the plan of care in response to identified patient
care issues and notifies the Clinical Supervisor
physician orders to cover additional visits and changes to the plan
patient care goals established in the plan of care, into nursing
care, as evidenced by documentation in nurses note.
those services ordered requiring substantial and specialized
appropriate preventative and rehabilitative nursing procedures
according to the plan of care.
medication regimen and updates medication profile according to
instructs and includes the patient and family in following the Plan
of Care and meeting nursing and related needs.
all infection control guidelines and standards per Agency
and provides clinical direction to the Licensed Practical Nurse &
the Home Health Aide to ensure quality and continuity of services
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
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
care coordination & changes to the appropriate team members as they
occur to the patient’s plan of care.
compliance with all fiscal intermediary and/or other third party
payers, through education, coaching, and other assistance as
current knowledge of, and promotes compliance with all federal,
state and local regulations.
fully cognizant of current Medicare, Medicaid, and third-party
reimbursement regulations and changes and ensures
the continuity of quality patient care delivered.
communication with Clinical Supervisor providing updates and
changes in schedules, patient data or needs, physician orders or
or communicates in patient care conferences offering clinical
suggestions and updates of patient’s progress towards
clinical notes indicate continuing communication and coordination
of services with physician, other staff and
effective time management skills by completing patient assignment
within projected time frame and arriving to appointments on
assigned cases to ensure compliance with requirements of third
that all assessment nursing notes, supply sheets and visit logs are
accurate, timely and turned into office according to office
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
commitment and professional growth.
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
the Agency philosophy, mission statement and administrative
policies to ensure quality of care.
patient & staff privacy and confidentiality at all times pursuant
to HIPAA Privacy Final Rule.
positive, supportive communication to physicians, patients,
families, visitors, and other agency personnel.
availability by phone as directed by company policy.
Agency image by adhering to the dress code.
to work as scheduled.
to work and patient homes promptly as directed.
the personal property of patients and their families with
all infection control guidelines and standards per Agency
minimum productivity requirements based on agency
by company policy and procedures as outlined by company policy
other duties as assigned by the Supervisor.
LICENSURE: Current State License
as a Registered Nurse.
EXPERIENCE: 2 year experience as a nurse in a
clinical care setting required.
SKILLS: Nursing skills as defined by accepted
HEALTH STATUS: Meets all applicable agency
policies and procedures related to health screening and required
Physical Requirements/Working Conditions:
1. Complete required work on a daily basis.
2. Cope with work involving ill, disabled, and dying
3. Sit, stand, bend, lift, and move intermittently. (Must be
able to lift 80-100lbs)
4. Move equipment and supplies necessary for job
5. Read, speak and write English in order to fulfill job
functions in an understandable way.
6. See/hear or use prosthetics that enable accomplishment of
7.Meet the health requirements of the agency.
8. May have possible exposure to infectious diseases.
9. Abide by all occupational safety and bloodborne pathogen
protocol to minimize illness and/or injury.
10.Move, support and/or transfer patients as required to
perform essential functions of position.