JOB DESCRIPTION-SKILLED NURSE
Position: Skilled Nurse
Position Supervises: Licensed Practical Nurses and Home Health Aides
Reports To: Director of Nursing and Assistant Director of Nursing
The Skilled Nurse:
• Will be a graduate of an accredited nursing program
• Will have a current Illinois license as a Registered Nurse.
• Have at least (1) year clinical nursing experience, preferable in rehabilitation or medical-surgical nursing (home health experience preferred)
• Have a current CPR certification.
• Possesses interpersonal, communication and organizational skills necessary to complete job responsibilities.
• Has an insured automobile and a valid driver’s license, or access to adequate transportation.
• Has the ability to make visits and provide skilled nursing assessments and skilled care in the home.
• Must not pose a “direct threat” to the health or safety of the individual or others in the workplace or in the job performance.
The Skilled Nurse has clinical nursing knowledge, physical assessment, teaching and procedural skills. He/she has the ability to be directly responsible for assessing, planning, providing and documenting nursing care for a designated group of patients in accordance with the physician’s plan of care and Advent Home Health Services, Inc.’s policies and procedures. The provisions of quality care is accomplished by implementing, supervising and coordinating services provided and utilizing to LPN’s, Home Health Aides and completes documentation affectivity and timely.
DUTIES AND RESPONSIBILITIES
1. Completes referrals and takes physician’s verbal orders as necessary in a timely manner. Channels referrals appropriately to Director of Nursing for assignment.
2. Makes home visits, performs physical assessment, evaluates patient’s needs and consults with physicians if necessary to develop plan of care and documents appropriately and in timely manner.
3. Assesses need for additional health or ancillary services and prefers patients for service(s) when appropriate, on a timely basis.
4. Assesses family and home environment and makes recommendations, which will enhance patient care and promote safety.
5. Involves patients and/or family in developing and revising an individualized care plan including necessary teachings with realistic goals, update plane of care as goals are met or change in intervention as required and documents changes appropriately within five (5) days.
6. Coordinates the multidisciplinary care team and plans for patient care and documents appropriately.
7. Interprets the admission, discharge and other policies of the company to patient, physician, family, other health care providers, and community as needed.
8. Provides clear, written and verbal Home Health Aide and LPN assignments, updates instructions for the aides and LPN’s in a timely manner and documents verbal instructions appropriately.
9. Provides skilled nursing care and assessments to patients in the home environments, according to the plan care and promptly revises the plan, as necessary, in consultation with the physician and other team member. Establishes and modifies goals as appropriate.
10. Informs and provide progress notes to the patient’s physician and podiatrist about patients under care. When the patient’s conditions changes or there are deviations from the plan of care and submit in writing patient’s summary of care at least every 60 days.
11. Initiate appropriate preventive, rehabilitative, comfort, pain management nursing procedures and provides instructions to patients/caregivers, and staff in a timely manner. Follows company policies and utilizes company forms in documenting forms.
12. Explains to the patient and family the diagnosis and the nature of the treatment consistent with physician’s orders and plan of treatment.
13. Performs LPN supervisory visits to evaluate competency, if necessary. Provides skilled services and appropriate instructions to LPN and documents accordingly.
14. Conducts Home Health Aide supervisory visits at least every two weeks either when the Home Health Aide is present to observe and assist or when the home Health Aide is absent to assess relationships and determine whether goals are being met.
15. Performs specialized care in accordance with the competencies and demonstrates initiative in learning new skills and developing competency.
16. Maintains assigned patient’s clinical records current including Medication Profiles, Plan of Care, Case Conferences, Program Notes, and other required documentation. Conducts patient care conferences (PT, OT, SLP) every three weeks from the start of therapy/care and report unusual occurrences/changes to the attention of the physician. The patient and the family are consulted and informed about all the changes in the care plan.
17. Completes clear, concise and accurate clinical notes which documents skilled services and other required documentation appropriately and submit on a timely basis. Utilizes only universal approved abbreviation.
18. Communicates necessary information to the Director of Nursing.
19. Demonstrates professionalism by maintaining high standards of clinical care and staying current on clinical and medical issues.
20. Attends and participates in multidisciplinary patient case conferences to demonstrate effective coordination and continuity of patient care, as well as, schedule cases to be brought to the clinical records review committee.
21. Conducts and documents formal and informal case conferences to demonstrate effective coordination and continuity of patient care, as well as, schedule cases to be brought to clinical records review committee.
22. Works with patient, family and health care team members effectively to coordinate services and to promote quality care and possible patient care outcomes.
23. Cooperates and is reliable with providing on-call coverage and marking PRN, Weekend and holiday visits to the patients.
24. Establishes and maintains working relationship and open lines of communication with personnel from physician’s offices, area hospitals, clinics, etc. to assure flow on information, referrals for service and continuity of care.
25. Completes nutritional assessments and provides patient/caregiver instructions on diet/nutrition and seeks consultation as necessary.
26. Uses appropriate teaching material and techniques to obtain position outcomes and seek consultation as necessary and documents patient/caregiver outcomes on company form.
27. Uses appropriate infection control procedures and safety measure.
28. Administrators CPR, provides emergency care necessary and maintains current CPR certifications.
29. Assists in orienting/precepting new staff when necessary.
30. Provides and documents services in accordance with State, Federal, Medicare, Medicaid regulations as applicable.
31. Provides and documents services in accordance with third party payer requirements and obtains prior authorization as required. Submits 485/recrt information timely, accurately and legibly. Notifies data processing of payer source changes in a timely manner.
32. Performs job duties and uses resources appropriately.
33. Coordinate with Administrator/DON program to improve deficient services and the development and implementation of plan of correction.
34. Adheres to policies and procedures of Advent Home Health Services, Inc.
35. Performs other duties as assigned by the Director of Nursing.