A Registered Nurse provides medical care and treatment, educates patients about their conditions, and provides emotional support to patients and families. Works in hospitals, schools, clinics or community health centers. Works under the supervision of a physician or other specialist, and serves as the primary point of care for patients in a hospital setting. May specialize in emergency room work, or treatment for a particular condition, or specialize in working with infants, the elderly or other patient groups. May work as an advanced practice specialists and prescribe medications in addition to offering specialty care.
The Registered Nurse (RN) is responsible for providing clinical oversight, assessments, care planning, and ongoing nursing supervision for members enrolled in the Adult Foster Care (AFC) and Group Adult Foster Care (GAFC) programs. The RN works collaboratively with Care Managers, caregivers, physicians, and interdisciplinary team members to ensure participants receive high-quality, person-centered care while maintaining compliance with MassHealth regulations and ABBA Home Care policies. Essential Duties and ResponsibilitiesClinical Assessments & Care Planning Complete initial nursing assessments for all new AFC and GAFC members. Perform reassessments and significant change assessments as required. Develop, implement, and regularly update individualized Plans of Care. Coordinate all required clinical evaluations and documentation. Review and update PCP Summary Forms and physician documentation. Prepare and submit required health status reports to Primary Care Providers. Member Monitoring Conduct required home visits in accordance with MassHealth regulations and agency policy. Monitor members' physical, mental, and functional health status. Identify changes in condition and communicate findings promptly to physicians, caregivers, and the interdisciplinary team. Coordinate appropriate interventions to maintain member health and safety. Assist with hospital discharges, transitions of care, and program discharges. Caregiver & Direct Care Oversight Train and orient AFC caregivers and GAFC Direct Care Aides before services begin. Provide ongoing education regarding disease processes, infection control, safety, documentation, and personal care techniques. Evaluate caregiver performance and competency. Provide clinical guidance and supervision to caregivers and Direct Care Aides. Review caregiver/direct care documentation and service logs at least every 30 days. Care Coordination Collaborate with Care Managers to ensure coordinated service delivery. Participate in interdisciplinary team meetings. Communicate effectively with physicians, hospitals, home health agencies, specialists, and community providers. Assist members and families in understanding care plans and available resources. Documentation & Compliance Complete all documentation accurately and within required timeframes. Maintain HIPAA compliance and confidentiality of protected health information. Ensure documentation meets MassHealth, agency, and accreditation standards. Participate in quality assurance, audits, and compliance reviews. Report incidents, safety concerns, abuse, neglect, or significant clinical findings according to agency policy. Quality Improvement Participate in Quality Assurance and Performance Improvement (QAPI) initiatives. Assist with regulatory surveys and audits. Maintain current knowledge of MassHealth
AFC/GAFC
regulations and nursing best practices. Participate in required staff meetings and continuing education.
