POSITION SUMMARY
Reports to: Clinical Manager
Provide services to clients in accordance with DC Nurse Practice Act, agency policy, and accepted professional standards of practice. The Registered Nurse provides nursing services, utilizing a comprehensive base of nursing theory and nursing processes and communicates/documents observations and assessments.
Essential Functions/ Areas of Accountability
1. Assumes responsibility and accountability for the practice of professional nursing in accordance with DC Nurse Practice Act and standards for home health nursing.
a. Performs comprehensive assessment of client status, including physical, psychosocial, and environmental parameters.
b. Develops and /or follows an individualized Plan of Care that incorporates analysis of data and current scientific findings.
c. Provides skilled interventions aimed at achieving realistic client outcomes within a specified time period.
d. Reports changes and information necessary to modify and update the Plan of Care to reflect progress towards goals(outcomes) as needed.
2. Consistently demonstrates competency with technical nursing skills according to personal and legal scope of practice:
a. Assessment skills as applied to the client, family/support system, and environment.
b. Teaching skills according to the client’s needs and within the context of the client’s environment, value system, and physical/emotional status.
c. Medication administrations: Check Patient’s medications each visit and report any changes in dose, new medications and discontinued medications and update changes in the Agency’s software.
d. Responsible for managing/supervising the care of patients assigned to you and supervising all permanent Personal Care Aides assigned to each patient.
e. Responsible for proper clinical documentation/measurable patient interventions and outcomes and answerable to Quality Assurance Nurse audits conducted randomly.
f. Follow up with Care Plan coordinator or office nurse coordinator on all physician orders written by you in consultation of the physician for timely physician signatures and nursing implementation
3. Nurses can visit the office at any time during office hours: 8:30 AM to 5PM and should be reachable by phone during office hours
4. Nurses will be called to the office during government audits for interview by government auditors if they have questions on any documentation on a patient in your assignment.
5. If your unskilled patient requires a skilled Oasis admission for PT&OT and/or Skilled nursing visits for wound care and /or medication and disease process teaching, you will be responsible for the Start of Care Oasis Assessment.
6. The Quality Assurance (QA) coordinator will do a thorough audit of 2-3 charts weekly for a nurse’s assignment and meet with the field nurse to discuss his/her findings and issue a remediation report if needed for a response within a month. The QA nurse will then repeat the exercise with the next nurse the subsequent week until all nurses have been seen and start all over again.
Managing the care of patients assigned to you:
1. Investigate Patient Incidents (Covid-19 and others) and Complaints and document following the Department of Health Care Finance (DHCF) and DC Health guidelines (DC Care Connect).
2. Perform annual Recertification assessments for the generation of revised patient’s annual Plan of Care and annual Home Health Aide Plan of Care
3. Instruct client/family/aide regarding abuse, neglect, and exploitation during Recertification assessment
4. Update Plan of Care with changes in patient diagnosis, medications, DME, diet, allergy, demographics and other patient health information as needed
5. Update Home Health Aide Plan of Care with changes in patient’s ADLs and health status as needed
6. Perform Resumption of Care assessments within 48 hours upon patient’s discharge from the hospital
7. Perform monthly supervisory assessment of fall, nutrition risks (assessing diet, weight loss/gain), disease process, medication management and resolving deficiencies and discrepancies with actionable and measurable interventions at each home visit and coordinate care accordingly with physician, PT/OT/ST for all patients and also with case managers with EPD Waiver patients.
8. Perform monthly supervisory assessment of permanent Personal Care Aides assigned to each patient and complete a nursing visit note and a Personal Care Aides supervisory note.
9. Supervise all newly assigned permanent PCAs within 48 hours post assignment.
10. Conduct a home oxygen safety risk assessment for each client on oxygen therapy, provide intervention and coordinate care with the oxygen Provider and other interdisciplinary team members as needed
11. Initiates the following documentation as needed:
Start of Care Assessments of New Patients
Physician Orders (For Medications, Diagnosis, Change in Home Health Aide (HHA) hours and DME requests)
Complaint Investigations
Incident Reporting via Incident Log + concurrent RN Monthly Visit Note
Infections via Infection Logs
Planned Discharges (In Allegheny)
Seizure Record
Resumption of Care Assessments
Home Health Aide Plan of Care updates following change in patient status
12. Coordinate patient care accordingly with physician, PT/OT/ST, patient’s responsible family member for all and case managers for EPD Waiver patients and document in DHCF and T&N Reliable software.
13. Perform medication reconciliation for each medication (name, dose, route, frequency, purpose, drug interactions) patient is taking at home versus medication ordered from hospital, patient’s physician(s) to identify and resolve discrepancies with patient, family and physician(s).
14. Instruct/Educate client/aide/family on diet, disease process, infection control practices, medication management and safety.
15. Responsible for progress summary for each patient every even month of the year.
16. Responsible for care coordination with case manager for EPD Waiver patients at least every even month of the year and as needed and document in the notes and progress summaries.
17. Responsible for care coordination for all patients with PT/OT/ST, physician, community social worker, adult day care center, dialysis center, responsible family member as needed and document in assessment notes and progress summaries
18. Participate in patient centered specific plan (PCSP) meeting developed by case manager for EPD Waiver patients and develop the Plan of Care with the involvement of the case manager for EPD Waiver patients.
19. Responsible for reviewing the PCSP annually from DHCF software and printing it to place in the patient’s physical chart or downloading into the T&N software.
20. If your patient census drops to 57 or below, the next new patient referral will be assigned to you to admit and build back your case load.
21. Instruct client/family/aide regarding abuse, neglect, and exploitation during Start of Care assessment, annual recertifications and as needed.
22. Participate in mandatory ongoing weekly, bi-weekly or monthly quality assurance continuous education meetings.
23. Initiate all physician orders in consultation with the physician, follow up with the Care Plan Coordinator to ensure that they are signed and then implement.
24. Understand each client's Emergency Protocol, Emergency Management Plan, Contingency Staffing Plan, Emergency Preparedness, and Beneficiary Emergency Notification Plan
25. Discharge clients leaving the Agency from your assignment in the Agency’s Software.
26. Notify Intake at least one month ahead of any decision to terminate your services or vacation plans.
27. Practices nursing with respect for individual, linguistic cultural and spiritual differences.
28. Reports significant changes in client status to the physician and other members of the team in a timely manner consistent with client needs and goals.
29. Maintains client records showing systematic assessments, planning intervention, and evaluation.
30. Document electronically on the agency’s software and according to agency documentation guidelines and standards.
31. Monthly documentation due the 7th of the succeeding(next) month includes:
RN Monthly Visit Note + concurrent HHA Supervisory Note
Progress Summaries for 60-day episodes (done for every even month of the year)
Monthly Care Coordination with case manager for EPD waiver patients and interdisciplinary team for all patients and document in the Care Coordination section of the RN Monthly Visit Note
Plan of Care updates to be made in the patient record (which includes medications, DME, changes in hours, changes in patient conditions, demographics, Physicians, Allergies, Responsible family member, code status)
32. Annual Documentation
Recertification assessments (to be completed between 75-90 days prior to expiration which comprises of a non-Oasis assessment, development of a Plan of Care and a Home Health Aide Plan of Care)
For EPD Waiver clients: Develop the Plan of Care in consultation with the case manager. Also, the RN will participate in the development of the Patient Centered Specific Plan (PCSP) by the case manager
33. Maintains confidentiality in all aspects of your duties.
34. Promotes personal safety and a safe environment for clients and coworkers.
Demonstrates knowledge of safety/infection control practices by compliance with established policies and procedures.
Recognizes and responds appropriately to potentially unsafe situations.
Demonstrates safe practices in the use of equipment.
Assesses safety of environment and takes initiative to help prevent accidents and promote safety.
35. Participates in ongoing, professional self-development.
Participates all mandatory education per agency guidelines.
Identifies needs for personal professional growth.
Demonstrates competency in areas of assignments or identifies the need for additional training (specialized equipment, etc.)
a. Supervises applicable home care team members as delegated by RN Clinical Manager and reports via email to the DON (
[email protected] )and administrator (
[email protected]) any Personal Care Aide whom you suspect his/her work attendance.
36. All Home Health employees should dress in uniforms and present a T& N Reliable ID at the patient’s home.
QUALIFICATION
1. Graduated from an accredited school of professional nursing, RN/BSN
2. Current license as a Registered Nurse in DC
3. Minimum of on (1) year experience in an acute care setting or equivalent experience
4. Current driver’s license, good driving record, and reliable transportation.
5. CPR certification
6. Strong communication and interpersonal skills
The RN should be able to perform the following skills:
Use of pulse oximeter, oxygen risk assessment and administration, use and understanding of ventilators, CPAPs and BIPAPs, tracheostomy care
Fall risk assessments and assessment of neuro signs
Management of patients with seizures, Diabetes, COPD, CHF, pain, infections, administration of medications, tube feeding, colostomy and ileostomy care, catheters, isolation techniques and infection control practices and proper waste disposal
Should be able to lift 50-75lbs weights, transfer patients from bed to chair, chair to bed and ambulate patients on a wheelchair and/or walker.
PHYSICAL/ENVIRONMENTAL DEMANDS
