Communicates relevant information timely and effectively with appropriate agency staff including but not limited to: any patient care issues or needs, visit assignments, dates of scheduled visits, and schedule changes to scheduler, orders and OASIS data sets, coding requests, schedule home visits, to coordinate care with other clinicians, Communicates timely and effectively with physicians, patients, and family members to ensure quality care and service excellence. Make the initial and/or comprehensive nursing evaluation visit, ensures patients meet home health eligibility and medical necessity guidelines as defined by payer source, accurately determines primary focus of care, develops the plan of care within State specific guidelines with the physician, and submits accurate documentation.