Under the supervision of the Home Health Supervisor, the Home Health Registered Nurse, utilizing the nursing process of ongoing assessment, planning, intervention, implementation and evaluation, is responsible for identifying patient/family needs and providing quality care/services in accordance with the attending physician’s orders, plan of care and Agency policies and procedures. Responsible for performing patient care on an intermittent basis in the patient’s place of residence in close coordination with other disciplines and caregivers involved in the patient’s care.
*Complies with Penn Highlands Community Nurses policies and procedures, and federal, state or local law and regulations
Uses the nursing process in delivery of care as evidenced by, but not limited to:
1. Obtains patient history and conducts appropriate patient assessment.
2. Collaborates with the health care team to develop and manage the individualized plan of care, involving patient, representative, and caregiver whenever possible.
3. Implements appropriate nursing care to meet patient needs and in accordance with the plan of care.
4. Processes orders and notifies physician and other healthcare practitioners of patient needs and changes in condition related to the plan of care.
5. Evaluates on an ongoing basis patient’s response to medical, nursing, and other disciplines’ interventions and takes appropriate action.
Demonstrates critical thinking and clinical competency in the delivery of patient care as evidenced by, but not limited to:
1. Administers medications, monitors effectiveness, and takes appropriate action as needed in accordance with policies and procedures.
2. Proficient in starting and managing IV administration.
3. Responds appropriately to changes in patient condition.
4. Consults medical record for pertinent patient information such as diagnostic test results, physician progress notes.
5. Implements the plan of care according to physician’s orders, nursing orders, clinical pathways, and nursing care standards.
6. Appropriately delegates to and manages patient care delivered by support staff.
7. Conducts patient care conferences on patients assigned to his/her care.
8. Seeks to increase knowledge of procedures for adequate patient care.
Provides patient, caregiver and family education, counselling, and discharge planning as evidenced by, but not limited to:
1. Identifies patient learning needs on admission and throughout the episode of care.
2. Collaborates with health care team to develop and implement the discharge plan.
3. Prepares patient and caregiver for appropriate home management regarding medications and the follow up plan of care.
Participates in the development of new staff as evidenced by, but not limited to:
1. Actively participates in the orientation including cultural and social integration of new staff.
2. When serving as a preceptor, collaborates with staff member, Staff Development Staff and Home Health Supervisor to manage the learning process and assist with developing individualized action plans as needs are identified.
Demonstrates professional accountability as evidenced by, but not limited to:
1. Achieves educational credits to meet licensing/certification requirements.
2. Participates in agency-sponsored inservice training as scheduled.
3. Presents information obtained at education conferences to staff members.
4. Participates in the development and advancement of departmental standards, policies and other clinical professional initiatives.
5. Conducts self in professional manner in dress, actions, and interpersonal communication.
6. Ensures environment of safety for patients, caregivers, and coworkers.
7. Informs Supervisor of patient care situations and departmental problems as appropriate.
8. Communicates appropriately with the scheduler or designee to ensure timely coordination of care.
9. Demonstrates effective problem solving skills for clinical and departmental issues.
10. Participates in peer review and Quality Assessment and Performance Improvement as assigned.
Supervises the home health aide according to Medicare Conditions of Participations which includes aide plan of care, assignments, instruction, and supervisory visits.
Documents according to Medicare Conditions of Participation and other regulatory bodies in a timely manner which includes utilizing appropriate ICD-10 codes, clinical notes, patient charges, computer documentation, knowledge and understanding of OASIS time points, and completion of charts.
Maintains knowledge of internal and community resources and programs and makes referrals appropriately and in a timely manner.
Participates in after hours on call which includes nights, weekends and holidays, as scheduled.
Thorough knowledge of and strict adherence to Penn Highlands Community Nurses Mission, Vision, and Values.
Performs other duties as assigned by management.
Education: A Registered Nurse with a valid PA Nursing License.
Experience: Two yearsof Registered Nurse experience in acute care or long term care setting or five years of Licensed Practical Nurse experience in hospital Emergency Room or Intensive Care prior to becoming a Registered Nurse preferred.
Required skills: Excellent time management skills. Strong written and verbal communication skills. Strong teaching skills. Ability to work well independently and within a multidisciplinary team. Valid PA driver’s license and reliable transportation.
Preferred Skills: Previous Home Health experience