Assesses patients' clinical status and environment to identify needs for treatment and personal care to address pain and other discomforting effects of the primary and related illnesses and conditions; Ensures that patient care needs are being met as identified in the initial, comprehensive and ongoing assessments of the patient's physical, emotional, psychological, spiritual and environmental conditions; Responsible for identifying, coordinating, and providing patient/family care to patients and families in their own home, skilled nursing facility or residential care facility (including the Center's unique residences); Participates in triage system of phone calls and performs, or assigns care to home patients as needed and to residential patients in accordance with their needs; Provides education/counseling/interventions necessary to provide comfort care and maximize the quality of life for the patient and family; Develops, evaluated and revises a written POC in conjunction with IDG members that meets the needs of the patient and their immediate family/caregivers; Participates in regularly scheduled IDG meetings; Develops Home Health Aide (CHHA) POC in accordance with patient's assessed needs and revises CHHA POC as changes in patient's needs occur. Maintains skills to meet patients' needs for nursing care to patients as prescribed by the physician and in the Interdisciplinary Group, including but not limited to: monitoring/tracking of Vital Signs, IV placement, comprehensive personal care, phlebotomy, medication administration and wound care; Authorizes, coordinates and supervises care of subordinate care providers, as prescribed in the Interdisciplinary Plan of Care, and in accordance with state, and federal regulations when using ancillary personnel, i.e.-Licensed Practical Nurses as well as Certified Home Health Aids, in order to meet the needs of the patient; Documents accurate and ongoing patient assessments and care.