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Req Number: 2460
Department: Home Health
Schedule: Per Diem
Shift: Days
Hours: Per Diem, Days
Job Details:
  • RN Required
  • 1 year of experience required

    Works under the supervision of the Manager of Home Care.  A registered professional nurse is responsible for the delivery of patient care in the patient's home through the nursing process of assessment, planning, implementation and evaluation.  Provides patient teaching and coordinates activities of ancillary personnel while maintaining standards of professional nursing and the policies and operating instructions of Memorial Healthcare Home Health/Hospice Agency.  Upholds the mission and values established by Memorial Healthcare.



     1. EDUCATION:  Graduate from an accredited school of nursing.  RN license from Michigan or a permit to practice.


     2. EXPERIENCE:  Home Health Care experience required.  BLS for Healthcare Providers is required.



     1. Assessment

         A.  Completes a comprehensive admission assessment on patients/families upon  first visit to home.

         B.  Documents all relevant information in admission assessment.

         C.  Completes OASIS assessments accurately and in required time frame per policy.

         D.  Completes necessary forms required for payer billing.

         E.  Completes assessments required for all programs in the required time frame.

     2. Plan of Care

         A.  Develops a comprehensive nursing plan of care with goals that have been mutually agreed upon  

               with patient/family.

         B.  Plan of care follows guidelines and requirements as indicated by program.

         C. Creates certification form (485) or appropriate plan of treatment within required time frames for  

              admissions and re-certifications.

         D. Plans appropriate number of visits for patient needs.

         E. Certification forms are complete and accurate.

         F. Updates the plan of care as indicated by patient status.

             (SCIC, ROC or when goals are met)

         G. Generates referrals to other disciplines as appropriate and in a timely manner.

         H. Develops aide assignment sheets in timely manner, completes appropriate referral forms and

              follows scheduling protocols accordingly.

    3.  Plan Implementation

         A.  Implements plan of care according to policy and procedure and within scope of  nursing practice.

         B.  Performs technical skills using correct procedures, including medication  administration and IV


         C. Uses appropriate safety precautions.

         D. Assists patient/family in utilization of community resources

         E. Notifies physician of significant findings, records and follows physician orders


    4. Evaluation

         A.  Evaluates and revises plan of care as necessary according to patient/family needs.

         B.  Participates in home health team conferences as scheduled.

    5. Supervision of staff

         A.  Supervises care provided by home health aides as indicated by program


    6. Documentation

         A.  Maintains accurate records as required and documents all necessary information  in clinical  

               records in a timely manner.

         B.  Documents assessments, interventions, and response to interventions indicating patient progress

               toward goals.

         C.  Documentation is accurate and concise.    

         D.  Completes required summaries for each patient.

         E.  Documents physician orders in a timely manner for all changes in visit schedule and new


         F.  Documents pertinent information regarding patients who do not convert to an admission.

        G.  Accurately documents visit times and mileage in computer.

     7. Referrals / Coordination of care

         A.  Seeks physician orders for appropriate discipline referrals

               (I.e. social work, PT, OT, ST, dietician)

         B.  Initiates referrals to appropriate outside resources as indicated:  (Care  management, meals on 

              wheels, medicaid waiver, social services, protective  services, etc.)

    8. Patient/family instruction

         A.  Implements appropriate patient/family teaching.

         B.  Evaluates and documents patient/family’s learning.

    9. Communication

           1.  Supervision

               A.  Observes proper chain of command.

               B.  Keeps program supervisor informed of changes in patient condition or status, especially those

                     requiring a change in visit frequency.

            C.  Maintains own patient schedule accurately.

               D. Turns in weekly patient schedule in the required time frame.

               E.  Responds positively to supervisor’s direction professionally accepting guidance.

           2.  Physicians

        A.  Keeps physician informed of changes in patient condition and response to plan of treatment.

               B.  Communicates professionally with physicians and their staff.

               C.  Assures all lab results are communicated to the ordering physician within  appropriate time


           3.  Other Team Members

         A.  Coordinates and maintains communication regarding patient care with the  following team

                members when applicable:

                         -Infusion pharmacists

                         -aides, social workers, therapists and dieticians

                  -emergency personnel, acute care departments

                         -case managers (waiver, managed care, etc.)

    10. Discharge planning

            A.  Develops realistic discharge plan for patients and documents progress toward  discharge.

            B.  Involves and informs patient / family of discharge plan.

            C.  Coordinates plan for discharge with all involved disciplines.

            D.  Notifies all appropriate team members of patient d/c.

    11. Communication/Relationships with Patient/families

            A. Approaches patients/families in a professional manner that reduces conflict and  prevents undue

                 stress and anxiety.

            B. Communicates and educates effectively to patients/families.

            C. Maintains professional boundaries with patients/families.

      12. On-Call:

             A.  Is available by pager during assigned on call time and responds to calls in appropriate time frame.

             B.  Responds to patient needs appropriately.

             C.  Provides appropriate follow-up as needed.

             D.  Documents on-call activities consistently in chart if indicated or on-call log.


      13.  Manages time effectively and maintains productivity.


      14.  Able to speak knowledgeably of the scopes of service that are available through  the home care organization.


      15. Acts as a resource for peers, assists in orientation of new staff and accepts student assignments. 


      16.  Maintains a clean and well groomed professional image in accordance with  department dress code.


      17. Complies with current regulatory, legal and safety requirements for home care practice.


      18. Reports to work on time and as scheduled in accordance with the attendance policy.

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