Responsible for case management of assigned patients in accordance with Agency policies and procedures and all other applicable procedures manuals, laws and relevant professional standards.
- Assumes responsibility and accountability for the practice of professional nursing in a manner consistent with Agency policies and the State Nurse Practice Act.
- Performs comprehensive subjective and objective admission and ongoing assessment of client status that includes physical, psycho-social, and environmental parameters.
- Formulates individualized plan of care that incorporates analysis of assessment data.
- Provides skilled interventions aimed at achieving realistic outcomes within a specified time period.
- Modifies and updates plan of care to reflect progress toward outcomes.
- Consistently demonstrates competency with technical nursing skills according to legal scope of practice.
- Implements teaching appropriate to the patient’s needs.
- Assesses knowledge level and identifies learning needs.
- Plans, teaches, supervises, and counsels patient and family regarding physical care, measures to promote improvement/recovery, symptom/complication management, expected disease progression, social/emotional care and community resources.
- Evaluates effectiveness of teaching and modifies accordingly.
- Promotes patient/family autonomy.
- Coordinates delivery of care along health care continuum utilizing Agency and community resources.
- Integrates knowledge of community resources into plan of care.
- Demonstrates working knowledge of internal and community resources.
- Utilizes supplies, medications and equipment in a responsible and cost-effective manner to achieve desired outcomes.
- Negotiates and collaborates with other health care providers to achieve expected outcomes of patient care.
- Assists patient to access resources according to prioritized needs.
- Assumes responsibility for safe and uninterrupted patient care for assigned caseload.
- Communicates effectively and in accordance with agency requirements.
- Relays significant changes in status to physician and other members of the team in a time period consistent with patient need.
- Maintains patient records showing systematic assessment, planning, intervention, and evaluation.
- Documents legibly and according to Right at Home documentation guidelines and accepted nursing standards.
- Demonstrates teamwork and effective communication to accomplish patient and agency goals/outcomes.
- Attends and actively contributes to interdisciplinary team or other required meetings.
- Shares area(s) of specialized expertise among and between teams. Initiates appropriate interdisciplinary referrals.
- Participates in Quality Improvement activities.
- Uses professional nursing judgment to delegate selected nursing tasks when determined safe and appropriate.
- Supervises those to whom nursing functions have been delegated on an ongoing basis and in accordance with regulatory and Agency requirements.
- Retains responsibility and authority for determining appropriateness of plan and implements corrective actions when necessary.
- Applies knowledge of clinical and administrative policies and practice procedures as outlined in Right at Home policy and procedure manuals.
- Communicates potential risk management issues appropriately.
- Reports abuse or unsafe/illegal practice as required by law.
- Graduation from an accredited school of nursing and one year’s clinical experience within the past 5 years or completion of an accredited refresher course within the past 2 years.
- Current State RN license.
- Knowledge and ability to provide skilled nursing care as defined in the State Nurse Practice Act.
- Current CPR Certification.
- Use of an insured automobile and a valid driver’s license or access to adequate transportation.
- Available for work on weekends and holidays as required.
- Read, write, speak, and understand English as needed for the job.
- Meets current health requirements to provide patient care.
Assumes responsibility for professional development and contributes to the professional growth of others. Participates in in-service education programs. (This requirement need not be met exclusively through agency sponsored in-service programs)
Primarily works in patients’ place of residence, travel required. Shift or visit times and days vary with patient needs.