Home Health RN

Patient Care & Oversight of the Plan of Care

• Prioritizes the care needs of a caseload of patience in accordance with physician’s treatment plan.
• Adheres to the standards of regulatory, legal, professional and ethical practice.
• Performs comprehensive skilled assessments of patient needs, appropriateness for service, including OASIS data set assessments at appropriate time points.
• Determines care needs and develops care plan in collaboration with physician and other disciplines as indicated and coordinates the admission procedures and communicates necessary information to the patient, family and physician.
• Initiates, coordinates and supervises services per the plan of care, i.e., nursing, HHA, PT, ST, OT, MSW, spiritual/bereavement, medical nutritional therapy and volunteers.
• Updates plan of care as patient needs require, communicates changes to other members of the health care team and obtains physician orders for changes in plan of care.
• Provides for the delivery of quality skilled nursing care and treatment in a compassionate, patient-centered manner.
• Develops individualized goals of patient care in collaboration with patient/family and health care team.
• Establishes a patient-centered plan of care that assures patient safety 24/7 with particular attention to anticipating planning for patient needs (i.e., emergency preparedness planning).
• Provides goal-oriented care with an emphasis on preventing rehospitalizations.
• Demonstrates competency with Medicare Conditions of Participation and insurance coverage guidelines and ability to review Patient Bill of Rights, HIPAA Notice of Privacy Practice, Advance Directives with patient, as well as other admission documentation as required by Agency.
• Demonstrates full competency with clinical documentation software, maintains patient care record via computer in an organized and timely manner.  Communicates information using current processes and technology available to the Agency.
• Ongoing assessment and referral to appropriate community services as necessary.
• Informs the physician and other team members of changes in the patient’s status in a timely manner and coordinates needed interventions.
• Facilitates patient conferences with family and/or other professional services, including the physician as needed and coordinates distribution of information to responsible parties to assure overall compliance with plan.
• Participates in ongoing review of cases to achieve patient goals consistent with the established plan of care.
• Evaluates outcomes of care.
• Promotes patient and family independence.
• • Participates with patient and family to establish health care goals that reflect their understanding of the disease process, supports their values, and reflects their informed choices.
  • Counsels and educates the patient and family regarding their disease, self-care and prevention strategies to achieve recommended goals.
  • Continually evaluates patient’s progress and assures a smooth transition to discharge when goals are attained.
• Participates in QI/QAPI activities including record review as needed.

Medications

• Responsible for the oversight and safe administration of medications on admission and at each visit, including:
• • Identification of all medications the patient is taking and assuring documentation of same in the physician’s plan of care.
  • Familiarity with and pertinent review of potential side effects and interactions of patient’s prescription and non-prescription medications, and allergies and education of patient and caregiver.
  • Assuring the implementation of a system for the patient to receive prescribed medications.  Devising and implementing an effective method of administration pursuant to the patient’s individual needs.
  • If pre-pouring medications, documents medications poured, doses and the frequency each day and time period (including dates and times).
  • Teaching patient/family medication actions/interactions/side effects and possible adverse reactions and appropriate action to take.
  • Evaluating the effectiveness of the medication regime, discussion with physician and documentation of reported changes.
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Supervision

• Supervises LPNs and paraprofessionals providing care.
• Develops and updates individual HHA plan of care for each patient.
• Supervises HHAs in the provision of care to assure safe implementation of the plan of care, and as required by regulation.
• Completes annual performance evaluations for assigned HHAs.
• Mentors staff and participates in orientation as assigned.

Documentation

• Documents complete history, review of symptoms, identification of problems, care given and plan for care in the record for each patient visit.
• Documents teaching to patients and families including what was taught, what written instructions were provided, return demonstrations an response to teaching.
• Completes documentation of care per agency guidelines.
• Documents communication with other agencies and insurance companies, including the contact and the contents of the conversation.
• Documents 10-day, 60-day and discharge summaries.
• Documents care in accordance with rules of the Community Health Accreditation Program (CHAP), agency policies and reimbursement and regulatory requirements.

Team

• Shares expertise and provides support to and with other team members.
• Attends and participates in team meetings and clinical staff meetings.
• Coordinates with all disciplines on each case to assure integrated approach to plan of care.
• Coordinates with agency intake and scheduling to assure that new admissions are promptly admitted to care.
• Coordinates with liaison nurse when patient is in hospital or other facility.
• Participates in weekend/holiday coverage according to agency requirements.

Educational

• Certified in CPR
• Attends yearly OSHA in-service and completes annual skills validation
• Identifies knowledge gaps and remedies independently
• Attends minimum 12 hours of in-services per year, including 6 hours of hospice in-service for staff caring for hospice patients.

Billing

• With intake and billing, explores all billing sources available to the patient.
• Communicates billing instructions to appropriate departments.
• Follows guidelines for the provision of care under Medicare and Medicaid.
• Participates in pre-billing review as needed.