- Initial and ongoing comprehensive assessments of the client's needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points.
- Initiating the plan of care and revising as necessary. -Providing those services and / or treatments requiring substantial and specialized nursing skill.
- Counseling the client and family in meeting nursing and related needs. -Initiating appropriate preventative and rehabilitative nursing procedures.
- Preparing clinical and progress notes. -Coordination of services. -Referral to other services as needed. -Informing the physician and other staff of changes in the client's needs.
- Evaluating the outcomes of care. -Re-evaluate the patient plan of treatment at least every 60 days and when there is a change in the patient condition, after a hospital stay, and at time of discharge revising the Plan of Treatment as needed to achieve patient goals.
- Supervising LPN / LVNs and paraprofessionals providing services. -Assigning home health aide to a specific patient. -Participating in in-service programs.
- Planning for the discharge from service. -Provides patients and staff supervision 24 hours a day when assigned on-call.
- Collaborating with leadership / management team and office staff to facilitate timely office processing of paperwork and personnel information.
- Actively participates in Agency quality improvement activities. -Promote the Agency and services to the public and participate in physician and community education related to services provided by the agency as registered.
- Performs other duties as assigned. -Maintains responsibility to develop professional self attend seminars, and identify self-learning needs, collaborates with agency leaders in meeting learning needs.
Licensed Practical and Licensed Vocational NursesMust be able to travel to prospective patient's place of residence
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