- Provides skilled care to patients requiring intermittent professional nursing service at home or in the Day Health Center. Instructs and supervises family members, auxiliary nursing personnel, or others providing nursing care. Coordinates plans for service with other disciplines in all care settings (including hospital, nursing home, etc.) Ensures provision of medical supplies and equipment services to patients. Assesses, evaluates and reports to physician patient’s physical and emotional condition, reaction to medications or treatments. Informs MD of the social and/or physical factors in the environment that may affect patient care. Plans and implements necessary multidisciplinary conferences with CLHC staff, patient and family. Maintains up-to-date patient record including care plans and recertification, reports of services rendered, progress notes and discharge summaries, 90 day PACE and/or 120 day Casa or State LTHHP packets. Participates in case conference. Assists patient’s families in understanding and accepting appropriate medical, hospital, nursing home or other care as necessary. Coordinates with team to arrange and communicate pertinent patient information to other health care providers as appropriate. Assists with orientation of new staff members and preceptorship of students. All other duties as assigned by Supervisor.