Via assessment of client, the RN will develop and implement a Plan of Care based on utilization guidelines and Clinical Pathways. The focus of service delivery is on providing the right mixes of services and service resources that result in the client achieving the Plan of Care. Proficient in use of OASIS. Knowledge of OSHA, JCAHO/CHAP, State and Federal standards. Familiar with payor reimbursement guidelines.
Essential Duties & Responsibilities:
Performs client admissions, resumption of care, follow-up using OASIS data
Identifies, documents and reports signs and symptoms of altered health status to physician and Clinical Team Manager.
Obtains appropriate orders to increase/decrease visit frequency. Obtains medical orders to alter treatment plan.
Develops Plan of Care consistent with clinical assessment findings, diagnosis, orders, HHRG Case Mix category, and appropriate utilization guidelines/clinical pathway specific to each client.
Administers meds and treatment according to Plan of Treatment.
Teaches nursing care appropriate to client’s condition.
Coordinates care, integrating other health team members.
Documents client records according to agency policy.
Notes progress towards discharge planning. Communicates with physician, and appropriate staff regarding discharge planning.
Supervises the LPN and Home Health Aide to ascertain compliance with Plan of Care.
Makes supervisory visits in home at least every 14 days.
Participates in back up call according to need of agency.
Maintains current knowledge of nursing/home care as well as agency’s policies and procedures via in-services, testing, skills labs, and on-going CEU’s.
Selects orients and assigns work for direct reports
Updates management regarding potential problems or concerns.
Maintains an understanding of the company’s scope of services.
Submits clinical documentation in a timely manner according to agency policy.
Performs other duties as assigned.
Self-Starter–Takes initiative identifies needs of co-workers and customers and solves problems.
Time Management – Managing one’s own time.
Critical Thinking – using logic and reasoning to identify the strengths ands weaknesses of alternative solutions, conclusions, or approaches to problems.
Able to perform the essential functions of the job with or without accommodation.
Graduate of an accredited RN program required. : Minimum two years experience as an RN with one year experience in Home Health (home health experience may be waived). Experience in geriatrics helpful. Work experience denoting communication and assessment skills.
Licenses, Certifications and/or Registrations:
Current RN license in the State of Florida. Current CPR certification. Current driver’s license and valid auto insurance. Completion of 25 CEU’s bi-annually.
Office/Home Environment. May be exposed to biological hazards.