Aachele Home Care and Hospice, LLC

Home Care Registered Nurse (RN) Job Description


Position Title: Home Care Registered Nurse (RN)
Department: Home Care / Skilled Nursing
Reports To: Administrator / Director of Nursing / Clinical Supervisor
Employment Status: Full-Time, Part-Time, PRN, or Contract, as assigned
Service Area: Client Homes and Other Approved Community Settings


Position Summary


The Home Care Registered Nurse (RN) provides professional, compassionate, and individualized skilled nursing services to clients in their homes. The RN is responsible for assessing client needs, developing and implementing the nursing plan of care, providing ordered treatments, monitoring changes in condition, educating clients and caregivers, coordinating services with physicians and other members of the healthcare team, and completing timely and accurate clinical documentation.


The RN is expected to provide care in accordance with the client's physician/provider orders, agency policies and procedures, applicable professional standards, and federal and Georgia requirements applicable to the services being provided.


Essential Duties and Responsibilities


Skilled Nursing Care


The RN will:

• Perform comprehensive and focused nursing assessments.
  
  
• Complete initial/admission nursing assessments when assigned.
  
  
• Obtain and document vital signs and other appropriate clinical measurements.
  
  
• Assess pain, mobility, nutrition, hydration, skin integrity, safety, medication use, and functional status as appropriate.
  
  
• Provide skilled nursing interventions according to physician/provider orders and the established plan of care.
  
  
• Monitor the client's response to treatment and identify changes in condition.
  
  
• Provide medication education and medication reconciliation as appropriate.
  
  
• Provide disease-process education and self-management teaching.
  
  
• Perform wound assessments and wound care according to provider orders.
  
  
• Measure, photograph, and document wounds when authorized and clinically appropriate.
  
  
• Monitor wounds for signs of infection, deterioration, or improvement.
  
  
• Perform other skilled nursing procedures within the RN's scope of practice and agency policy.
  
  
• Notify the physician/provider and clinical supervisor of significant changes in condition.
  
  
• Assist with preventing avoidable emergency department visits and hospitalizations through early identification and reporting of clinical concerns.
  
  

Admissions and Start of Care


When assigned an admission, the RN will:

• Complete the initial nursing assessment within the timeframe required by the agency, payer, referral source, or applicable regulation.
  
  
• Review the client's diagnoses, medications, allergies, physician orders, recent hospitalizations, and current healthcare needs.
  
  
• Identify immediate safety and clinical concerns.
  
  
• Verify that required orders are available for skilled services.
  
  
• Establish or contribute to the client's individualized plan of care.
  
  
• Educate the client and/or caregiver regarding services, medications, treatments, emergency procedures, and when to contact the agency or physician.
  
  
• Coordinate necessary follow-up with the physician/provider and agency clinical team.
  
  
• Complete all required admission documentation accurately and timely.
  
  

Plan of Care


The RN will:

• Follow the physician/provider-approved plan of care.
  
  
• Review the plan of care for continued appropriateness.
  
  
• Recommend changes when the client's condition or needs change.
  
  
• Ensure nursing interventions are consistent with current orders.
  
  
• Communicate changes in the client's condition to the appropriate provider and agency supervisor.
  
  
• Obtain or facilitate new or revised orders when required.
  
  
• Participate in reassessments, recertifications, supervisory visits, and discharge planning as assigned.
  
  

Wound Care Responsibilities


When providing wound care, the RN will:

• Follow the current wound care order.
  
  
• Assess wound location, size, drainage, odor, wound bed, surrounding skin, pain, and other clinically relevant findings.
  
  
• Document wound progress and response to treatment.
  
  
• Immediately report signs of infection, significant deterioration, uncontrolled bleeding, increased pain, or other concerning findings.
  
  
• Educate clients and caregivers regarding wound protection, infection prevention, dressing care, nutrition, pressure relief, and other ordered interventions.
  
  
• Communicate with wound care providers and physicians when clarification or modification of treatment orders is needed.
  
  

Medication Management


The RN will:

• Review medications during admission and subsequent visits as appropriate.
  
  
• Identify and report medication discrepancies.
  
  
• Educate clients and caregivers regarding medication administration, purpose, precautions, and potential adverse reactions within the RN's scope.
  
  
• Notify the appropriate provider of significant medication concerns.
  
  
• Document medication education and identified concerns.
  
  

Client and Caregiver Education


Education may include:

• Disease management
  
  
• Medication management
  
  
• Wound care
  
  
• Fall prevention
  
  
• Infection prevention
  
  
• Nutrition and hydration
  
  
• Skin protection
  
  
• Safe use of medical equipment
  
  
• Signs and symptoms that should be reported
  
  
• When to call the physician, agency, 911, or seek emergency medical treatment
  
  

The RN will document education provided and the client's or caregiver's understanding and response.


Care Coordination


The RN will communicate and coordinate care, as appropriate, with:

• Physicians and other authorized healthcare providers
  
  
• Nurse practitioners and physician assistants
  
  
• Agency nursing staff
  
  
• Home health aides/personal care staff
  
  
• Physical, occupational, and speech therapy providers
  
  
• Wound care providers
  
  
• Hospitals and rehabilitation facilities
  
  
• Pharmacies
  
  
• Durable medical equipment providers
  
  
• Laboratories
  
  
• Family members and authorized caregivers
  
  
• Other members of the client's healthcare team
  
  

Documentation Requirements


The RN is responsible for complete, accurate, and timely documentation.


Documentation should clearly reflect:

• Reason for the visit
  
  
• Assessment findings
  
  
• Vital signs when appropriate
  
  
• Skilled nursing interventions performed
  
  
• Wound findings and treatment, when applicable
  
  
• Medication review or concerns
  
  
• Client response to treatment
  
  
• Education provided
  
  
• Communication with physicians/providers
  
  
• Changes in condition
  
  
• New or revised orders
  
  
• Follow-up needed
  
  
• Progress toward established goals
  
  
• Coordination of care
  
  

Clinical documentation must be completed according to agency policy and required payer or regulatory timeframes.


Change in Condition and Emergency Responsibilities


The RN will:

• Promptly recognize and report significant changes in condition.
  
  
• Contact the physician/provider and agency supervisor when clinically indicated.
  
  
• Initiate emergency procedures when necessary.
  
  
• Instruct the client or caregiver to call 911 when an immediate emergency exists.
  
  
• Document the change in condition, persons notified, instructions received, interventions performed, and client outcome.
  
  
• Complete incident reports when required by agency policy.
  
  

Supervisory Responsibilities


When assigned, the RN may:

• Conduct supervisory visits.
  
  
• Evaluate whether services are being delivered according to the established plan of care.
  
  
• Assess client satisfaction and continued service needs.
  
  
• Provide clinical direction to LPNs/LVNs and other personnel when permitted by applicable law and agency policy.
  
  
• Report performance or care concerns to agency leadership.
  
  
• Participate in quality improvement and clinical record review activities.
  
  

Scheduling and On-Call Responsibilities


The RN must:

• Maintain assigned client visits and communicate scheduling concerns promptly.
  
  
• Arrive within the established visit window whenever reasonably possible.
  
  
• Notify the agency of missed, refused, or rescheduled visits.
  
  
• Participate in the agency's on-call rotation when assigned.
  
  
• Respond appropriately to client changes in condition while serving on call.
  
  
• Maintain reliable communication with agency leadership during assigned working and on-call periods.
  
  
• Accept admissions and urgent nursing assignments according to availability, competency, agency policy, and assigned responsibilities.
  
  

Infection Control and Safety


The RN will:

• Follow standard precautions and infection-control practices.
  
  
• Perform appropriate hand hygiene.
  
  
• Use personal protective equipment when indicated.
  
  
• Properly handle and dispose of contaminated materials and sharps.
  
  
• Identify environmental and safety hazards in the client's home.
  
  
• Report suspected abuse, neglect, exploitation, unsafe conditions, or other reportable concerns according to agency policy and applicable law.
  
  

Professional Expectations


The RN is expected to:

• Protect client confidentiality and comply with HIPAA requirements.
  
  
• Maintain professional boundaries.
  
  
• Treat clients, families, caregivers, and coworkers with dignity and respect.
  
  
• Maintain reliable communication with the agency.
  
  
• Attend required meetings, training, competency evaluations, and in-services.
  
  
• Maintain required licenses, certifications, and credentials.
  
  
• Practice within the RN's authorized scope of practice.
  
  
• Immediately report any restriction, suspension, expiration, or other change affecting the RN's professional license or ability to perform assigned duties.
  
  
• Represent Aachele Home Care and Hospice professionally in the community.
  
  

Minimum Qualifications

• Current, active Registered Nurse license in the state in which services are provided.
  
  
• Graduate of an approved nursing education program.
  
  
• Current CPR/BLS certification, if required by agency policy or assignment.
  
  
• Current driver's license and reliable transportation when travel is required.
  
  
• Current automobile insurance when using a personal vehicle for agency business.
  
  
• Ability to successfully complete required background checks, screenings, and competency requirements.
  
  
• Home care, skilled nursing, geriatric, wound care, or related clinical experience preferred.
  
  

Required Skills


The RN should demonstrate competency in:

• Nursing assessment
  
  
• Clinical judgment
  
  
• Care planning
  
  
• Wound assessment and treatment
  
  
• Medication review
  
  
• Client and caregiver education
  
  
• Infection prevention
  
  
• Change-of-condition assessment
  
  
• Emergency response
  
  
• Clinical documentation
  
  
• Physician/provider communication
  
  
• Care coordination
  
  
• Time management and independent field work
  
  

Physical Requirements


The position may require the ability to:

• Travel to client residences.
  
  
• Stand, walk, bend, reach, and perform nursing procedures.
  
  
• Assist with positioning or transferring clients when clinically appropriate and safe.
  
  
• Carry nursing supplies and equipment.
  
  
• Work in varying home environments.
  
  

Reasonable accommodations will be considered as required by applicable law.


Confidentiality


All client, employee, clinical, and agency information must be maintained in strict confidence. Unauthorized disclosure of protected health information or confidential agency information may result in disciplinary action up to and including termination and may have legal consequences.


Acknowledgment


I acknowledge that I have received and reviewed the Home Care Registered Nurse (RN) Job Description. I understand the responsibilities and expectations associated with this position. I understand that this job description describes the general nature of the position and may be modified as necessary to meet client needs, agency operations, payer requirements, and applicable laws and regulations.


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Aachele Home Care and Hospice, LLC