POSITION OVERVIEW

This position is responsible for providing total patient care for each home health patient that is based on the individual patient care plan and medical care plan with appropriate age-specific assessments, interventions, evaluation and care implementation. This position is also responsible for providing patient and family education as the foundation of nursing care.

ESSENTIAL FUNCTIONS OF JOB

: (other duties may be assigned) Complete initial assessment of patient and provide ongoing assessments. Complete assessment data and identify patient problems on admission visit with documentation completed within 24 hours. Develop a plan of care for each individual patient based on the assessment. Evaluate the patient's response to interventions and set goals with the patient and family. Maintain concise documentation in nursing notes within 24 hours of all care provided. Report changes in the patient's condition as necessary to the physician. Maintain confidentiality of patient's personal, medical, and financial information. Provide total patient care based on the individual care plan. Provide age-specific intervention based on patient plan of care and Medicare plan. Perform treatments and procedures in adherence to policies and procedure standards. Evaluate and document patient response to care as needed. Notify the physician as patient condition warrants. Recertify the patient's plan of care every 60 days. Follow the five patient rights - right patient, right medication, right route, right time and right dosage. Accurately document administration of medication immediately following the activity. Administer IV therapy and ensure appropriate tubing changes and site care is performed per policy and properly document same. Observe patient for signs/symptoms of infection and properly document same. Perform phlebotomy procedures per protocol. Complete lab order forms correctly. Incorporate interdisciplinary intervention to maximize patient outcome. Asses and reassess patient needs on each visit. Refer to appropriate therapy Home Health Aide, Physical or Occupational Therapy, Speech Therapy, Medical Social Workers, or HHA services. Document patient response per procedure. Document information for home health certification and plan of care. Complete

HCFA 486

within 24 hours of the patient's admission. Coordinate patient discharge. Begin planning discharge at the time of admission. Contact appropriate referrals and perform follow-up. Ensure understanding of discharge instructions by the patient and family. Notify the physician of the discharge and complete the OASIS form. Provide clinical oversight of the nursing care process. Serve as a resource for staff including the licensed practical nurses, nurse aides, and other ancillary staff. Delegate nursing care duties as appropriate for the scope of practice of assignee. Serve as the case manager responsible for caseload or assist the primary case manager. Observe staff with patients to ensure quality care and patient satisfaction on joint visits. Communicate with staff regarding any changes in patient care as needed. Direct staff to ensure 100% compliance with WMC policies and procedures. Teach medications and various techniques, treatments and procedures to patients, caregivers, and staff members. Evaluate patient and caregiver understanding of techniques by successful return demonstration on each visit. Instruct and receive return demonstration by staff members as needed. Document teaching upon completion of demonstration. Review patient medication profile with patient and caregiver on each visit. Assist in identifying educational needs of staff, patients, and caregivers. Allow time for questions and further instruction for patients and caregivers at each visit. Provide 24 hour on call coverage. Maintain contact with hospital via phone and cell phone. Contact physician and Home Health supervisor as patient condition warrants. Visit patient or provide telephone intervention and document in Doc Com. Must remain up to date, knowledgeable, and compliant on all DOH and other applicable regulatory related to your department and area. Patient safety regulations and goals will be followed (i.e. using 2 patient identifiers, reporting critical values, medication reconciliation, etc) Perform appropriate documentation regarding narcotics administration (i.e. second signature for count and waste, etc.) Follow the regulations regarding restraint and seclusion, sentinel event notification, etc. Attend appropriate educational programs related to regulatory standards, updates, and initiatives. Qualifications

QUALIFICATIONS

Education/Training/License/Certification :

Valid Pennsylvania licensure as a Registered Nurse required; Valid Pennsylvania driver's license required. Current Cardio-Pulmonary Resuscitation Certification required.

Work Experience :

One year of experience and/or training in a nursing field required.

Driving Record :

If deemed a driver in your position, a valid Driver's license and proof of insurance are required. 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