POSITION SUMMARY: Provides intermittent nursing service to patients in their homes under a plan of care established in collaboration with the patient#s physician and according to agency policies and procedures. Admits clients to service, establishes a plan of care and refers to other disciplines and agencies, as necessary. # EDUCATION/CERTIFICATION: Graduate of an NLN-approved school of nursing, associate, or baccalaureate degree program. Possession of a current license to practice as a Registered Nurse in the State of Connecticut.# # EXPERIENCE: One (1) year of experience in community health nursing home care or hospice is required. # COMPETENCIES: Knowledge of professional nursing theory and practice and the skills to practice and evaluate patient care. Knowledge of Agency policies, regulations, and procedures to administer patient care.# Knowledge of medical equipment currently used to provide patient care. Knowledge of common safety hazards and precautions to establish a safe work environment. Skill in applying and modifying the principles, methods, and techniques of professional nursing to provide ongoing patient care.# Skill in identifying patient-related problems and recommending solutions. Skill in documentation in clinical records and use of Electronic Medical Record. Skill in establishing and maintaining effective working relationships with patients, families, physicians, co-workers, and the community. Ability to maintain quality control standards. Ability to react calmly and effectively in emergency situations. Ability to interpret, adapt and apply guidelines and procedures. Ability to communicate clearly. Possess adequate transportation to carry out job requirements. Must show proof of satisfactory automobile insurance with State of CT minimum coverage, recommended amount of $100,000/300,000. Willingness to provide service in any part of Agency geographic area, according to Agency need. # ESSENTIAL DUTIES and RESPONSIBILITIES: Disclaimer: Job descriptions are not intended, nor should they be construed to be, exhaustive lists of all responsibilities, skills, efforts or working conditions associated with the job. They are intended to be accurate reflections of the principal duties and responsibilities of this position. These responsibilities and competencies listed below may change from time to time.# Eastern Connecticut Health Network reserves the right to change or assign other duties and responsibilities to this position. # Admits/readmits patients and provides intermittent nursing service to patients and their families in compliance with agency policies and State and Federal Regulations, incorporating the following: a)## A complete physical and psychosocial assessment. b)## Develops and implements an appropriate care plan and therapeutic goals with the patient/family. c)## Evaluation of patient safety on a 24-hour basis. d)## Exercises appropriate clinical judgment in coordination of patient care by all services involved. e)## On going evaluation of significant changes in the condition of the patient and of progress toward the therapeutic goals. f)### Use of Agency and community consultants/resources. g)## Instruction of patient/family in procedures or responsibilities they are assuming and optimum wellness practices. h)## Planning for the patient#s discharge from service. Related duties should be grouped together in one responsibility statement. Establishes and maintains case mix weight, utilization, patient satisfaction that aligns with industry standards and agency operational objectives for quality care. a)## OASIS documentation correlates with the Plan of Care. b)## Uses recommended Oasis assessment techniques 100% of the time. c)# OASIS, documentation, and plan of care correlate to 95%. Documents all services provided in the clinical record in accordance with State and Federal Regulations and Agency policy: a)## Documentation, including activities and mileage is exported within 36 hours of visit or prior to next scheduled visit. b)## Obtains physician verbal/written orders and complies with all reporting requirements. c)## Participates in coordination of care with physicians and with other disciplines as appropriate. Manages work assignment in effective and efficient manner: a)# Visits all new therapeutic clients within 24 hours of referral unless otherwise specified # #####by the physician. b)# Reports any cases to the Supervisor of Clinical Services where goals cannot be met or at-risk situations exist and respond appropriately. c)# Remains flexible in daily planning, allowing time for emergencies or unexpected visits. d) ##Maintains productivity as established by the Agency. e)## Utilizes payer sources correctly, reflecting changing levels of care. f)### Delegates patient care responsibilities to Home Care Nurse (LPN) as appropriate. g)## Demonstrates an understanding of the principles of case management. h)## Demonstrates ability to manage cost and quality. Establishes and evaluates the Plan of Care to be delegated to the Home Health Aide, orients and supervises the Home Health Aide in accordance with State and Federal Regulations and Agency policy: a)## Develops written plan of care for the Home Health Aide and updates this plan as patient#s condition warrants; plan of care must be reviewed every 60 days. b)## Obtains input from Home Health Aide regarding patient progress. c)## Prepares written performance evaluations of home care aides under his/her supervision. d)## Provides supervision of home care aides at a minimum of every 14 days or as required by payer source. Develops and maintains sufficient professional skills and credentials to meet the needs of patient care: a)## Attends a minimum of 12 hours of in-service per year to include mandated annual in-services. b)## Participates actively in self-appraisal and the formation of a plan of self-development. c)## Adheres to Agency Corporate Compliance Plan and HIPAA Privacy Plan as per written agreement. d)## Seeks appropriate clinical input to ensure appropriate patient care. e)## Projects professional image through attitude and compliance with dress code. f)### Capable of precepting new nurses and students. g)## Functions as a team member with consideration for all staff. h)## Provides Agency with current copy of professional license. Performs other duties as necessary to support Agency programs as assigned by the Supervisor of Clinical Services. Abides by Agency weekend/holiday rotation of nurses. May provide back-up for on-call service. Team assignments may change with or without notice based on agency needs. # #