POSITION SUMMARY

The Home Health Admission Nurse is a Registered Nurse responsible for completing timely, accurate, and comprehensive Start of Care (SOC) and other assigned admission-related assessments for patients referred to the Home Health agency. The Admission Nurse evaluates the patient's clinical condition, homebound status, skilled care needs, medications, safety risks, functional limitations, caregiver support, and overall eligibility for Home Health services. The nurse coordinates with physicians or other authorized practitioners, referral sources, the Clinical Manager, Intake, Scheduling, Therapy, and other members of the interdisciplinary care team to establish an individualized Plan of Care. The Admission Nurse is expected to complete all required assessments and documentation accurately and timely in accordance with agency policy, payer requirements, applicable state regulations, and Medicare Conditions of Participation.

ESSENTIAL DUTIES AND RESPONSIBILITIES 1.

Admission and Start of Care Perform comprehensive Start of Care assessments for newly admitted Home Health patients. Verify that the patient's clinical condition and skilled needs are consistent with the referral and available orders. Evaluate whether the patient meets applicable Home Health eligibility requirements. Assess and document the patient's homebound status when required by the payer. Identify the primary reason for Home Health services and ensure the clinical documentation supports the patient's current skilled needs. Review available hospital, rehabilitation, physician, and referral documentation before or during the admission. Identify discrepancies or missing information and communicate them promptly to the Clinical Manager and appropriate department. Complete assigned SOC visits within required agency and regulatory timeframes. Immediately escalate situations in which the SOC cannot be completed as scheduled. 2. Comprehensive Patient Assessment Complete a thorough assessment that includes, as applicable: Current medical condition and diagnoses Recent hospitalization or change in condition Vital signs Cardiopulmonary status Neurological status Gastrointestinal and genitourinary status Musculoskeletal and functional status Pain assessment Skin integrity and wound assessment Nutritional status Fall and safety risks Cognitive and behavioral status Activities of daily living Mobility and assistive devices Medication management ability Caregiver availability and support Psychosocial needs Emergency preparedness Environmental and home safety concerns Need for skilled nursing, therapy, Home Health Aide, social work, or other ordered services Immediately report significant abnormal findings, changes in condition, or urgent safety concerns according to agency policy. 3. OASIS Responsibilities For Medicare and other OASIS-required patients: Complete the applicable OASIS assessment accurately and comprehensively. Ensure OASIS responses are consistent with the patient's clinical assessment and supporting documentation. Avoid assumptions and document findings based on assessment, observation, patient/caregiver interview, and available clinical records. Address QA or coding clarification requests promptly. Correct documentation when appropriate while maintaining the integrity of the clinical record. Participate in OASIS education, competency assessments, and performance improvement activities as required. 4. Plan of Care Development Develop an individualized Plan of Care based on the patient's assessment, physician/practitioner orders, diagnoses, functional limitations, goals, and identified skilled needs. Recommend appropriate disciplines and visit frequencies based on patient needs. Establish measurable and patient-specific goals and interventions. Coordinate the Plan of Care with the patient, caregiver, physician/practitioner, and interdisciplinary team. Ensure that ordered services are reasonable, necessary, and supported by the clinical assessment. Notify the Clinical Manager of services, treatments, supplies, or frequencies requiring additional review or clarification. 5. Medication Reconciliation Perform complete medication reconciliation during the admission. Review actual medication containers whenever available. Compare medications in the home with referral documents, hospital discharge instructions, medication profiles, and physician orders. Identify medication discrepancies, duplications, contraindications, potential interactions, expired medications, or medications the patient is not taking as ordered. Communicate significant discrepancies to the physician/practitioner and Clinical Manager. Educate the patient and caregiver regarding medication administration, precautions, and medication safety within the nurse's scope of practice. Document physician notification and resulting orders or instructions. 6. Physician and Provider Coordination Communicate with the physician or authorized practitioner regarding admission findings, significant abnormalities, medication discrepancies, and recommended services. Obtain or clarify orders as required. Ensure verbal orders are documented and processed according to agency policy. Assist in identifying missing or incomplete Face-to-Face documentation when applicable and notify the appropriate office department. Maintain professional communication with physicians, hospitals, rehabilitation facilities, pharmacies, infusion companies, DME providers, and other members of the patient's care team. 7. Patient and Caregiver Education Provide education appropriate to the patient's condition and Plan of Care, including: Disease management Medication management Fall prevention Infection prevention Wound care when applicable Emergency procedures When and how to contact the agency When to contact the physician When to call 911 Home Health services and patient responsibilities Patient rights and responsibilities Agency complaint procedures Emergency preparedness Infection-control practices Assess and document the patient's and caregiver's understanding of the education provided. 8. Care Coordination and Handoff Provide a complete clinical handoff to the assigned case manager or primary nurse. Communicate priority problems, wounds, medication issues, pending orders, laboratory needs, IV therapy, high-risk conditions, and upcoming appointments. Notify Scheduling and Clinical Management of the recommended visit frequency and urgency of follow-up. Coordinate therapy evaluations when ordered. Identify patients requiring immediate or next-day clinical follow-up. Participate in case conferences, clinical huddles, and other interdisciplinary meetings as assigned. 9. Documentation Standards The Admission Nurse is responsible for complete, accurate, and timely clinical documentation.

Documentation must:

Reflect the patient's actual condition at the time of assessment. Support the need for skilled Home Health services. Support homebound status when required. Be consistent throughout the clinical record. Clearly describe skilled interventions and clinical findings. Include appropriate physician/provider communication. Identify patient-specific risks and interventions. Meet agency, payer, state, and federal documentation requirements. All admission documentation should be submitted within the timeframe established by agency policy to prevent delays in coding, QA review, physician orders, scheduling, and billing. 10. Quality and Compliance Responsibilities The Admission Nurse shall: Follow Medicare Home Health Conditions of Participation and applicable payer requirements. Follow applicable OASIS requirements. Follow agency policies and procedures. Participate in QA and QAPI activities as requested. Respond timely to QA and coding clarification requests. Participate in chart audits and corrective-action activities. Maintain patient confidentiality and comply with HIPAA requirements. Report suspected abuse, neglect, exploitation, unsafe conditions, or other reportable concerns according to applicable law and agency policy. Maintain professional and ethical nursing standards.

PRODUCTIVITY AND PERFORMANCE EXPECTATIONS

Performance may be evaluated based on: Timeliness of Start of Care completion Timeliness of documentation submission OASIS accuracy Completeness of medication reconciliation Accuracy and completeness of clinical assessments Appropriate identification of skilled need Quality of Plan of Care development Appropriate physician communication Number of documentation corrections or QA returns Patient and caregiver education Effective clinical handoff Attendance and reliability Communication and responsiveness Compliance with agency policies Patient safety outcomes Productivity expectations will be established by the agency based on geographic coverage, patient complexity, travel requirements, documentation requirements, and employment status.

MINIMUM QUALIFICATIONS

Current and unrestricted Registered Nurse (RN) license in the state(s) of practice. Graduate of an accredited nursing program. Current CPR/BLS certification. Valid driver's license and reliable transportation when travel is required. Current automobile insurance as required by agency policy and applicable law. Ability to travel throughout the assigned service territory. Ability to use an electronic medical record system and mobile technology. Home Health experience strongly preferred. Previous OASIS experience strongly preferred. Admission/SOC experience preferred. Strong clinical assessment and critical-thinking skills.

REQUIRED COMPETENCIES

The Admission Nurse must demonstrate competency in areas applicable to assigned patients, including: Comprehensive nursing assessment OASIS assessment Medication reconciliation Fall-risk assessment Infection prevention Wound and skin assessment Pain assessment Cardiopulmonary assessment Neurological assessment Diabetes management Patient education Emergency procedures Care planning Physician communication Documentation Home Health eligibility and homebound assessment Identification and reporting of changes in condition Additional competency validation may be required before independently admitting patients requiring specialized services such as IV therapy, central lines, complex wounds, drains, ostomies, tracheostomies, or other high-risk procedures.

COMMUNICATION EXPECTATIONS

The Admission Nurse is expected to maintain timely and professional communication with the Clinical Manager, Intake, Scheduling, QA, Coding, Authorization, Orders Management, physicians, and other members of the care team. Urgent clinical concerns must be escalated immediately. Routine messages and requests for clarification should be acknowledged and addressed within agency-established timeframes. The Admission Nurse must promptly report: Hospitalization or emergency department transfer Significant change in condition Medication discrepancies with potential patient-safety implications Missing critical orders Patient refusal of essential services Unsafe home conditions Suspected abuse or neglect Inability to complete the SOC Patient not meeting admission criteria Staffing or scheduling barriers affecting patient safety Other significant clinical or compliance concerns

PHYSICAL REQUIREMENTS

The employee must be able to perform the physical functions necessary to provide nursing care in a patient's home environment, including standing, walking, bending, reaching, carrying clinical supplies, and assisting with patient assessment and mobility as appropriate. Reasonable accommodations may be provided in accordance with applicable law.

WORK ENVIRONMENT

This position requires travel to patients' residences and other community-based settings. The nurse may encounter varying environmental conditions, pets, stairs, limited space, weather-related travel conditions, and other circumstances associated with community-based healthcare. The Admission Nurse is expected to follow agency safety procedures and immediately report unsafe situations.

PROFESSIONAL EXPECTATIONS

The Admission Nurse is expected to: Demonstrate professionalism and respect. Protect patient confidentiality. Maintain appropriate professional boundaries. Communicate effectively with patients, families, coworkers, and external providers. Accept feedback from QA and Clinical Management. Complete required education and competencies. Maintain required licenses and certifications. Report to work and assigned visits as scheduled. Notify management promptly of delays, absences, or barriers to completing assigned admissions.

Pay:

$95,000.00 - $105,000.00 per year

Benefits:

401(k) 401(k) matching Dental insurance Free parking Health insurance Health savings account Life insurance Mileage reimbursement Paid sick time Paid time off Referral program

Work Location:

In person