Job Function
Provides direct patient care services to patients in their residence and coordinates care planning with other disciplines and Clinical management as needed in order to achieve favorable patient outcomes through appropriate case management. Working corridor will be 5:00 p.m. to 8:30 a.m., with on-call visits from 5:00pm – 11:00pm and hospice only visits from 11:00pm – 8:30am.
Essential Functions/Responsibilities
- Maintain the highest level of work ethic, and adherence to organizational policies and procedures, objectives and safety standards.
- Maintain highest level of confidentiality. Does not communicate confidential employee/ employer/patient information to others.
- Will respond to triage RN quickly and be at patient's home when needed within one hour.
- Provide direct care to clients to meet after-hours needs in a timely manner.
- Makes the initial evaluation visit, provides direct nursing service, nursing case management as needed to clients in their place of residence focusing on ensuring continuity of care and providing positive patient outcomes.
- Provides direct care to clients in nursing home, inpatient facilities and in respite care settings as indicated for hospice clients.
- Provides continuous care to hospice clients as needed.
- Assess patients nursing needs and develops a comprehensive plan of care with physician, client, and other members of the home care and hospice team.
- Informs the physician and other involved personnel of changes in the patient's condition and needs.
- Counsels/Instructs the patient and family in meeting nursing and related needs.
- Furnishes those services requiring substantial and specialized nursing skill and initiates appropriate preventative and rehabilitative nursing procedures to adequately meet patients/agency
- Maintain medical paper supplies (e.g., admission charts, revocation and transfer forms).
- Works with Team Leader as needed in a timely manner with regards to new admissions, ROC's and recertifications.
- Prepares clinical and progress notes and is accountable for client records including:
- Plan of treatment: Source document (485487) which is reviewed and approved after admission visit.
- Client assessment: Which is done on admission and updated as new problems develop.
- Nursing care plan: Initially done on admission and reviewed and updated with the addition of new problems and interventions.
- Visit record: Completed during each visit on the laptop computer, with the client. The record includes all pertinent assessment findings; all services rendered; description of unusual findings/circumstances; unstable conditions; interventions; referral to other professionals, physician contacts; dates of physician visits and emergency contacts.
- Tree View: Completion/Verification of all key folders in the Tree View at time of admission. The folders are reviewed each visit and updated as changes occur.
- Verbal orders: Documentation of changes to key items which makes up the 485 will generate a verbal order.
- Discharge of client: According to Agency procedure and including a discharge summary.
- Participates in Conferences with therapy and ancillary staff. (Participation is mandatory and frequency is outlined in Agency policy. Meetings may cover other topics or problems the nurse is encountering.)
- Participates in professional development and activities, which will increase knowledge of community nursing.
- Attends all mandatory in-services and meetings annually.
- Maintains current knowledge and understanding of Federal/State regulations and facilitates proper utilization of health care resources.
- Maintains current knowledge of insurance reimbursement including Medicare and Medicaid guidelines.
- Meets Agency standards in demonstrating competency in clinical practice for homecare and hospice.
- Represents the Agency in the home and community in a professional manner.
- Continually re-evaluates client status and response to care and services provided. Revises and updates patient plan as needed and completes appropriate verbal order forms for physician signature as indicated.
- Responsible for planning discharges from Agency with client/family as required by federal law and as relates to nursing and long term planning and documenting same in client record.
- Responsible to complete the Outcome Assessment Information Set (OASIS) as mandated by Federal regulations.
- Participates in Quality Assurance Program, Chart Audit, and Utilization Review as requested by Patient Care Manager.
- Performs other duties as assigned.
Equipment Used:
Venipuncture/glucose monitor/BP cuff/catheters/syringes/irrigations: Frequent/essential
Enemas/Hoyer Lift: Occasional/essential
IV pumps: Occasional/marginal. (IV certification required.)
Copier/computer/printer/label maker: Frequent/Essential
Telephone: Frequent/Essential
Fax Machine: Occasional/Essential
Calculator: Seldom/Essential
Automobile: Frequent/Essential
Physical Demands - Body Position and Movement:
Sitting: Frequent/Essential
Standing/Walking: Frequent/Essential
Lifting/Pushing: Occasional/Essential
Pushing/Reaching/Pulling: Seldom/Marginal
Kneeling: Occasional/Marginal
Crouching/Stooping/Squatting/Twisting Upper Body: Seldom/Essential
Climbing Hand-Over-Hand: None
Physical Demands Object Manipulation
Fine hand movement: Frequent/essential.
Environmental Demands
Work environment requires in-person, field work.
Extreme cold/heat: Frequent/essential.
Temperature swings/extreme noise: Frequent/Essential
Outdoors: Frequent/essential.
Indoors: Frequent/essential.
Conditions which may aggravate an allergy: Frequent/essential.
Hazards
This position is classified as exposure category I concerning occupational exposure to the hepatitis B virus (HBV), the human immunodeficiency (AIDS) virus (HIV), and the tuberculosis virus as defined by the Department of Labor/Department of Health and Human Services.
Requirements:
Current licensure as a Registered Nurse in the State of New Jersey. One year of nursing experience preferred but not required. Bachelor's degree in Nursing preferred but not required. Home health experience preferred but not required.
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