PRIMARY JOB RESPONSIBILITIES
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
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
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
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
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.
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.
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:
-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.
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.