Summary

Organizes, coordinates and directs the ongoing provision of the services to the patients assigned to them within the agency.  Ensures the delivery of quality patient care and when appropriate, provides supervision during all service hours including, but not limited to supervision of LPN's and CNA's as required.  Initiates and maintains communication with the patients, families, physicians, other home health/hospice team members and agencies as needed to promote positive patient outcomes and appropriate use of healthcare resources.  Performs the initial and follow-up comprehensive assessments, drug regimen reviews and reconciliation.  Works with the patient, family, physician, other home health/hospice team members to develop and update the plan of care.  Documents into the EMR at point of care to ensure up-to-date patient records so that problems, plans, actions and goals are accurately and clearly stated, and changes are reflected as they occur. Completes required physician summaries at SOC, Recert, Transfer, ROC and discharge.  Documents any communication with the home health/hospice team.  Maintains an accurate visit schedule to reflect projected and actual patient visits.  Participates in the agency's Nurse on-call schedule, weekly case conference meetings, and the Quality Assurance and Performance Improvement (QAPI) Program.  Demonstrate familiarity with policies of the agency and rules and regulatory agencies, which aid in determining policies.  May be assigned other duties as appropriate.

Qualifications

• Graduate of accredited school of nursing


• Bachelor's and/or Master's degree preferred


• Current RN Missouri license in good standing


• Minimum two years of varied work experience as a professional nurse and preferably one of the two years in a home health/hospice setting


• Demonstrated skill in administrative performance including expertise with both written and oral communications and documentation requirements


• Demonstrated ability to assess and respond to the needs of patients and families in varied settings


• Demonstrated skill in nursing practice


• Ability to cope with family emotional stress and tolerance of individual lifestyles


• Ability to perform necessary documentation in writing


• Ability to lift, transfer and/or move items or patients weighing 10-200+lbs and who vary with ability to assist using proper lifting techniques and with assistance when necessary


• ability to perform critical thinking and psychosocial assessments and judgments


• Ability to drive in all types of weather


• Manual dexterity and skillful use of hands when working with patients and equipment