A nurse currently licensed and registered in the state of practice, which provides professional services within the scope of nursing practice standards in collaboration with primary care physicians, teaches and educates clients and their families. Professional skilled nursing is performed under the supervision of the Administrator, Director of Clinical Services (DCS) or Branch Manager.
Reports to the D.C.S., Branch Manager, or Administrator
Qualifications: (Preferred unless required by law)
- Graduate of an approved professional nursing program
- Currently, licensed “in good standing” in the state where skilled home visits will be provided.
- Minimum of one (1) year of experience as a professional nurse (may be waived at the discretion of the Administrator).
- Evaluation of potential GAFC participants
- Contact with participants PCP to obtain medical information and physician clearance
- Completion of the medical component of the GAFC participant assessment form
- Monitoring of the GAFC participant health status and completion of semi-annual participant status report and patient care plan
- Planning, implementation, and evaluation of foster care setting
- Provision of case management
- Supervision of personal care services q 60 days
- Receives the intake referral information and prepares paperwork/tools necessary for the visit.
- Obtains all pertinent medical history from client, family or significant others.
- Performs home safety check and environmental assessment of the client’s home environment.
- Performs the socio-psychological evaluation of the support systems available to the client and documents necessary emergency contacts etc.
- Performs assessment visit and documents accordingly (i.e. OASIS/ Skilled Nursing Note etc.).
- Performs physical examination and review of all body systems and documents such accordingly.
- Develops an appropriate and effective Plan of Care (POC) to be submitted to the physician for approval and implementation.
- Determines medical necessity for other services that could enhance the positive outcome desirable for the case.
- Evaluated the client’s ADL and IADL abilities and therefore need of support services such as home health aide.
- Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan the beginning of each certification period.
- Supervises the HHA every 2 weeks (in accordance with state/federal requirements) and documents the supervision without having to be directed to do so.
- Orders “other” professional services that are effective and is willing adjust frequency of these services as outcome progresses and the client’s condition warrants.
- Reviews billing processes with client and/or family advising client and/or family when co-pay or Medicare is not likely to pay for services (ABN).
- Effectively communicates with client and family the POC and progression of such. Keeps the client informed ongoing.
- Effectively communicates with other disciplines in the case (case conferencing) to effectively and appropriately problem solve as situations arise.
- Communicates effectively with the DCS or Nursing Supervisor scheduled visits planned and changes to the schedule on a weekly basis. Caseload is self-scheduled but communication of the clinician’s schedule is essential.
- Communication with the client’s physician (verbally and/or in writing) to obtain effective treatment modalities and/or rehabilitative therapy modalities to effect the best means to obtain the desired outcome for the specific medical problem that caused the case to open and/or recertify.
- Communicates in the case conferencing sessions to establish best practices for the individual client’s needs.
- Submits accurate, complete paperwork at the end of every week so that all medical records are intact and up to date. Uses the drop box if the office is already closed for the weekend.
- Submits ALL OASIS documentation within 48 hours of the OASIS visit, WITHOUT exception.
- Submits requests for re-authorization of “more visits needed” prior to third party insurers authorized number of visits expiring.
- Coordinates Community Services that may be available to the client to assist in safe home care needs.
- Understands that the fiscal and clinical management of each case is directly linked to the success of his/her office. Assures that visits are not done that cannot be billed.
- Participates in the Performance Improvement Committee process as requested to do so.
- Performs at least 5 clinical record reviews (CRR) per month in collaboration with the Nursing Supervisor. Submits the CRR timely each month.
- Participates in the monthly staff meeting as part of the requirements of the position. Adjusts visits on the staff meeting day to accommodate this important function.
- Participates in the growth of the office by being a willing preceptor for newly hired, same discipline employees.
- Participates in the planning, operation and evaluation of the nursing services of the organization.
- Maintains professional licensure and actively seeks out educational experiences to enhance the practice of home care nursing for her/him and the benefit of the clients serviced.
- Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the client caseload as quickly as possible relative to the event’s occurrence.
- Submits written time requests 2 weeks or more in advance of planned time off.
– Is able to lift, turn and transfer patients weighting up to 200 pounds.
– Is able to carry bundles up stairs weighing up to 10 pounds.
– Must be able to stoop and bend.
– Must be able to travel to prospective patient’s place of residence.
– Must be able to hear and speak in a manner understood by most persons.