Essential Functions: • Completes initial and ongoing assessments to identify the physical, psychosocial, and environmental needs of home health patients/clients • Completes assessments at appropriate time points, including Outcome and Assessment Information Set (OASIS) or other assessments as appropriate to the patient • Regularly re-evaluates the patients/client's nursing needs and evaluates the outcomes of care • Develops, initiates, and revises the plan of care as necessary to ensure quality and continuity of care • Initiates appropriate preventive and rehabilitative nursing procedures • Refers to other services as needed • Plans for the discharge of the patient/client from services • Furnishes those services requiring substantial and specialized nursing skill • Counsels the patient/client and their family in meeting nursing and related needs • Uses infection control measures that protect both the staff and the patient (OSHA) • Coordinates services • Informs the physician and other personnel of changes in the patients/client's condition and needs • Monitors assigned cases to ensure compliance with requirements of third party payors • Prepares clinical and progress notes • Completes appropriate documentation in a timely manner • Demonstrates commitment and professional growth by participating in in-service programs and maintaining or improving competency • Supervises, teaches and provides clinical direction to other nursing personnel • Assigns home health aides to specific patients • Supervises LPNs/LVNs and paraprofessionals providing services to patients/clients • May only conduct aide competency evaluations if qualified with two years of clinical experience and one year of home health experience • Promotes the Agency's philosophy and administrative policies • Performs on-call responsibilities and provides on-call services to patients/clients and their families as assigned • Provides effective communication to patients/clients, their family members, team members, and other health care professionals. Our exceptional Care Team members are the heart of what we do and include incredible nurses, medical social workers, aides, chaplains, and dedicated volunteers who work together to support both patients and their families.