A. BASIC PURPOSE

The Registered Nurse (RN) is responsible for planning, coordinating, and documenting skilled professional nursing care provided to meet patient needs twenty-four (24) hours per day, seven (7) days/week for a geographically assigned caseload from the day of admission through day of discharge. Utilizing physician's orders and professional skills, the RN functions as a case manager and develops and implements a home health plan of care that meets each patient's specific needs, and is in compliance with state and federal home health regulations, reimbursement guidelines, as well as agency policies and procedures. The RN utilizes the nursing process which includes the use of technology, therapeutic intervention, evidence-based practice and coordination of care with other health team members to achieve positive clinical outcomes with the home health patients. The home health RN is responsible for the on-site supervision of the Home Health Aide. The RN participates in weekend, holiday and on-call rotation and is able to carry a patient load of 5 to 7 visits per day.

B. PRIMARY RESPONSIBILITIES

Nursing Process

As a member of the Ideal HomeHealth Care team, the Registered Nurse utilizes the nursing process to contribute to each patient’s total plan of care.

Assessing and Planning

1. Conducts initial nursing assessment through use of the OASIS assessment tool, and including physical and psychosocial aspects of patient/family/caregiver in a thorough, accurate, compassionate and timely fashion.
2. Utilizes own special body of knowledge to provide leadership and guidance to the home health team in formulating and individualizing the plan of care relative to the problems identified, interventions required, and goals that must be addressed relative to the patient needs.
3. Contributes to identifying both active and potential needs of the patient and his/her family which may affect the plan of care, and refers to other disciplines to assist the patient/family as needed and required.
4. Consistently collaborates with the physician to plan and implement the medical and nursing plan of care.
5. Reviews the comprehensive plan of care with the home health team.
6. Communicates in writing in the chart and verbally with co-workers and supervisors to coordinate interventions and ensure continuity of care.
7. Facilitates and participates in team meetings and contributes to patient care planning.

Implementing and Evaluating

1. Facilitates the implementation of nursing interventions and appropriate preventative and therapeutic nursing procedures through the provision of direct patient care and supervision of home health aide services.
2. Collaborates with other team members (physician, therapists, medical social workers and aides) to provide continuous assessment of assigned patients, interpret findings, initiate appropriate therapeutic actions, refer other disciplines, and evaluate the results of these actions.
3. Accepts responsibility of assignment to perform a specialized procedure only when qualified with specialty training, proven competency, clinical background, and expertise in the specialty area.
4. Works in cooperation with family/caregiver and home health team members to meet the emotional needs of the patient, family and/or caregivers.
5. Provides appropriate information, teaching and explanation to the patient’s family regarding care. Facilitates patient and family education to promote continuity of care and optimal patient/family outcomes.
6. Demonstrates expertise in the utilization of all team members.
7. Assists in the investigation and resolution of quality issues in conjunction with the Director of Nursing/Clinical Manager and/or Administrator.
8. Fulfills productivity requirements on an average daily census basis as determined by acuity level and Director of Nursing/Clinical Manager and/or Administrator.
9. Documents accurate, complete and relevant clinical notes regarding patient’s condition and care given.

Education

1. The Registered Nurse is a mentor who is able to provide educational experiences and communicate knowledge of patient care to members of the home health team including, but not limited to, patient, family and/or caregivers, other nursing staff, home health aides and the general community.
2. Acts as a mentor who facilitates individual staff development from novice to expert. Participates in the orientation of new personnel and assists with field training as needed.
3. Identifies the learning needs of the home health staff and other health care professionals, and facilitates formal and informal inservices, and patient care conferences to promote professional growth of all team members.
4. Teaches patient, family and/or caregiver disease process and self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by physician, and recognizes and utilizes opportunities for health counseling of patient, family and/or caregivers.
5. Facilitates the development of teaching aids to promote patient, family and/or caregivers’ learning.
6. Evaluates effectiveness of educational experiences in order to promote ongoing professional development of home health staff and quality patient, family and/or caregiver outcomes.
7. Supervises the home health aides and licensed practical nurses on-site per agency policies.

Management

1. The Registered Nurse oversees her caseload and responsibilities in order to support clinical and operational goals and objectives.

Manpower

1. Coordinates patient care assignments and scheduling of visits so as to provide optimal patient care and efficiently organize care and services.
2. Ensures visit frequencies are according to individual patient needs and acuity.
3. Reviews visit frequencies at least weekly and alters to meet patient needs and acuity.
4. Coordinates patient care visits with team members in order to utilize manpower resources and provide optimal patient care.
5. Participates in evening/weekend call as required, conducting on-call services in a clinically competent and responsive manner.
6. Maintains regular attendance.
7. Develops home health aide plan of care; introduces the home health aide to the patient, family and/or caregivers; supervises the home health aides every 14 days, or more frequently as needed to guarantee that the plan of care is implemented, followed and that patient and family are satisfied with the care and services being provided.
8. Performs an on-site supervisory visit of the Licensed Practical Nurse (LPN) at a minimum of every 30 days or more frequently as needed.

Operational

1. Ensures adequate and appropriate inventory of supplies and equipment for the provision of patient services and promotes the efficient use equipment and supplies.

Personnel

1. Provides timely supervision and counseling of home health aides and LPNs which is constructive and encourages growth.
2. Strengthens problem-solving ability of home health aides and LPNs.
3. Maintains confidentiality in matters related to co-workers.

Leadership

1. Demonstrates behavior appropriate to a role model and leader. Adheres to a code of conduct, conducive with agency policy.
2. Demonstrates creativity and critical thinking ability when developing patient care plans or completing assigned projects.
3. Assumes leadership role to facilitate care coordination and collaboration.
4. Functions without supervision, utilizing time constructively and organizing assignments for maximum productivity.
5. Collaborates with the home health team and effectively utilizes supervisor to problem- solve.
6. Participates in agency meetings and activities as directed and requested.

Communication

1. Introduces self and clarifies role to patient, family and/or caregivers, physicians, facilities and referral sources.
2. Recognizes and responds appropriately to verbal and non-verbal cues.
3. Communicates effectively with all members of the home health team by:
a. Defending and supporting peer/team decisions and actions.
b. Asserting self with tact.
c. Supporting collaboration.
d. Maintaining open communication.
e. Offering suggestions and criticisms constructively.
f. Asking questions and sharing information during conferences.
g. Maintaining confidentiality in all areas .
4. Relates complete and pertinent information in verbal and written communication. Maintains clinical records, statistics, and reports as prescribed and in compliance with local, state and federal laws.
5. Initiates and maintains open and effective communication with the Director of Nursing/Clinical Manager as well as other members of the home health team, as evidenced by improved patient outcomes.

Quality Improvement

1. Participates in the Quality Assessment and Performance Improvement process.
2. Facilitates active, ongoing problem-solving, which reflects home health team participation.
3. Pursues problems to resolution, and/or refers them utilizing the appropriate chain of command.
4. Assumes responsibility for personal growth and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and inservice classes.
5. Complies with local, state, and federal laws, home health Medicare regulations and established personnel policies and procedures.
6. Maintains all appropriate state nursing license requirements.

Other

1. Completes a minimum of 12 hours of inservices per year.
2. Participates in meetings and other related activities as needed.
3. Conducts all business activities in a professional and ethical manner and adheres to the agency’s code of conduct.
4. Meets or exceeds delivery of service standards in a consistent fashion.
5. Interacts with all staff in a positive and motivational fashion supporting the agency’s mission.
6. Creates and maintains a professional atmosphere.
7. Complies with local, state and federal laws, Medicare regulations and established agency policies and procedures.

The primary responsibility statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

C. HUMAN RELATIONS

1. Must maintain a professional attitude and demeanor and be able to communicate effectively and relate courteously and cooperatively with patients, caregivers, colleagues, supervisor, co-workers and all others.
2. Must be able to demonstrate optimism, enthusiasm and willingness to work constructively with other health care team members and reflect concern for the well-being of patients and others.

D. PHYSICAL REQUIREMENTS (See Attached Physical Requirements Form)

1. This position requires the Registered Nurse to work in a variety of environments (housing styles, cleaning and maintenance, heating and cooling) during visits to patients in their place of residence.
2. Visual/hearing ability must be sufficient to comprehend written/verbal communication.
3. The Registered Nurse must have ability sufficient to ambulate throughout a patient's home, navigating stairs and other physical barriers typical to private residences.
4. The Registered Nurse must be able to operate a motor vehicle and travel to and visit in patient’s homes in varying weather and road conditions.
5. Must be able to deal effectively with stress.

E. EDUCATION AND EXPERIENCE

1. Education Graduate of an accredited nursing program, Baccalaureate degree in nursing or related field, preferred.
2. Experience
a. Minimum of 2 years’ clinical nursing experience in general nursing with home health experience preferred.
b. Demonstrates excellent written and verbal communication skills.
3. Licensure, Registration, and/or Certification
a. Must possess current and valid license as a professional Registered Nurse to practice in the Commonwealth of Pennsylvania under the Professional Nursing Law (63 P. S. § § 211—225.5). Valid driver’s license and reliable transportation that is insured in accordance with Pennsylvania requirements.
b. Satisfactory references from employers and/or professional peers.
c. Satisfactory criminal background check.

I have read and understand the Registered Nurse job description. It has been reviewed and discussed with me and I have had the opportunity to ask questions regarding same.