Location: New York,NY, USA
NYC Health + Hospitals/Community Care reaches outside the walls of our hospitals and brings health care to patients where they live. With more than 600 dedicated employees, Community Care provides services including home care, community care coordination, and community-based care management to individuals managing chronic health conditions residing in Brooklyn, Manhattan, Queens and The Bronx. At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons. Job Description Under the direction of the supervising Assistant Director of Nursing in Community Care, assesses, plans, implements, and evaluates the patient's plan of care. Provides direct skilled nursing care and observes and instructs the patient in their place of residence. May coordinate services of other caregivers. Duties & Responsibilities 1. Provides individualized skilled Nursing care to the patients requiring part-time intermittent professional nursing service through the use of the nursing process. 2. Provides assessment of patient and develops a plan of treatment and care with ongoing evaluation of patient/family needs for other services. 3. Provides professional nursing services as outlined in the patient's plan of treatment and authorized by patient's physician, and provides emergency treatment as needed. 4. Records physical, social, psychosocial and environmental needs of the patient. Provide ongoing monitoring of the patient in the home care setting and escalates any clinical changes to the physician or non-physician provider as needed. 5. Utilizes input from patient, caregiver, MD and peers to devise a Nursing Care Plan which is feasible within the physical, financial and emotional resources of the patient/caregiver and the Department of Health (DOH) regulations. 6. Evaluates patient's response to plan of care (POC) as necessary, consistent with physician's orders. 7. Reviews and revises plan of care as necessary, consistent with physician's orders. 8. Plans activities necessary for effectuating the timely discharge/transfer of patient, and notifies all appropriate parties including patient's physician. 9. Authorize & coordinate all services including nursing, rehab, respiratory therapy, nutritional services, equipment, professional and non-professional staffing and support services. 10. Collaborates with case managers and other disciplines regarding the patient's progress and discharge plans. 11. Demonstrates a professional attitude and ethical conduct in compliance with departmental standards. 12. Involves the patient and caregiver actively in goal setting. 13. Establishes and maintains a cooperative, effective working relationship with the staff, physician and nonphysician providers, Case Managers and other hospital personnel, outside vendors, agencies and the community at large. 14. Attends weekly to bi-monthly team meetings and participates in case conferences and case load reviews on a weekly to bi-weekly basis. 15. When needed completes Physician's Orders in a timely manner. 16. Completes admission paperwork, including OASIS, Physician and Nursing POCs and progress notes within 48 hours of visit encounter. 17. Reviews clinical records to ensure compliance with departmental and regulatory standards. 18. Obtains written orders for all verbal orders returned. Maintain up-to-date patient files with complete records including care plans and re-certifications, reports of all services rendered, progress notes and discharge summaries. 20. Writes clean and concise progress notes that reflect the implementation of the plan of care and the patient's response to that plan of care. 21. Competent in knowledge of patient teaching plans and interventions. 22. Competent in knowledge of safe administration and teaching medications. 23. Demonstrates safety and accuracy in performing treatments and procedures according to the Home Care Department standards of care/practice. 24. Competent to complete thorough and accurate nursing assessments. 25. Demonstrate competence in skilled nursing interventions. 26. Competent in knowledge of documentation requirements for Home Care. 27. Participates in case conferences and/or Interdisciplinary Team conferences as needed and as designated by the Clinical Manager. 28. Works with other members of the Interdisciplinary Team to develop appropriate interventions in order to achieve clinical and functional goals. 29. Participates in the agency's Quality Assurance Performance Improvement/Performance Improvement Plan (QAPI/PIP) as assigned. 30. Supervises and monitors the care given by home health aides and ensures proper documentation. 31. Participates in an interdisciplinary health care team in determining and implementing a comprehensive plan of care. 32. Participates in the coordination of other professional and para-professional services in the home and provides supervision as needed and per DOH regulations. 33. Provides patient/family/significant other/patient identified representatives with teaching and involves them in assessment activities and goal setting. 34. Maintains current, complete, and appropriate documentation in the patient care record. May be required to use computer systems in carrying out these functions. 35. Duties include but may not be limited to wound care, including NPWT/VAC, Peg/Trach Care Management, Foley insertion and catheter care management, JP/PleuRx Drain care, administering injections. 36. Provides teaching on disease and medication management. 37. Obtains photographs for consultation by wound specialists. 38. Ability to apply evidence-based practices to the home care setting. 39. And other duties as ordered/prescribed. Minimum Qualifications QUALIFICATIONS FOR THE JOB: CERTIFICATION(S)/LICENSE(S): Licensed and currently registered to practice as a professional nurse in New York State; and Current certification in Basic Life Support procedures including CPR. EDUCATIONAL LEVEL: Baccalaureate Degree in Nursing from an approved program preferred. KNOWLEDGEABLE IN: Demonstrated knowledge regarding Federal, State and local regulations and JCAHO standards for Home Care. Excellent verbal, written, organizational and analytical skills. Demonstrated competence as a registered nurse in patient assessments and critical thinking skills. Previous experience using various computer software applications: i.e., Word, Excel, Access, etc. Department Preferences EQUIPMENT/MACHINES OPERATED: Smart phone Laptop Computer Desktop Computer Multifunction Copier COMPUTER PROGRAMS/SOFTWARE OPERATED: EPIC H2O Hyperspace EPIC H2O Remote Client Microsoft Office (Outlook, Word, Excel, PowerPoint, Visio, OneNote) YEARS OF EXPERIENCE: Minimum two (2) years of full-time nursing experience At least 2 years of experience in Homecare, Long-term Care, or Hospital setting