Job Description

Occasional Home Care visits required. 1. Utilizing the nursing process, assesses patient/care giver needs in order to provide quality care to assigned patients, in accordance with evidence-based practice, State and Federal regulations, Vermont State Board of Nursing and VNAHSR policies and regulations.. 2. Develops and communicates a realistic plan of care for each patient in accordance with evidence-based practice, State and Federal regulations, Vermont State Board of Nursing and VNAHSR policies and regulations. Ensures that the patient/care givers are included in the care plan process. 3. Serves as Case Manager for assigned patients and actively manages case loads and visit times in accordance with agency productivity standards. 4. Effectively fills out and completes OASIS documentation in accordance with Agency policies and procedures, and State and Federal regulations, Demonstrates knowledge of, and keeps up-to-date on changes to OASIS documentation requirements as needed. Ensures documentation is competed in accordance with Agency practice (timeliness.) 5. Implements medical plan of care, nursing interventions, and procedures as necessary to ensure the safe effective quality of care for patients in accordance with evidence-based practice, State and Federal regulations, Vermont State Board of Nursing and VNAHSR policies and regulations. 6. Stays up-to-date on a variety of High-Tech skills; IV use and maintenance, wound VAC, complex wound care, etc. Takes action to ensure that infection control standards re maintained throughout plan of care. 7. In accordance with LPN scope of practice, works collaboratively with LPN s to ensure that the plan of care is followed, delegates tasks and ensures that patient needs are met. Consistently reviews documentation, annotates visit notes and acts on recommendations in accordance with department policies and procedures. 8. Evaluates a variety of aspects of implemented plan of care including, but not limited to identified problems, care provided and patient s responses, to meet patient/care giver needs and ensure overall quality of care delivered, in accordance with evidence-based practice, State and Federal regulations, Vermont State Board of Nursing and VNAHSR policies and regulations. 9. Maintains up-to-date and accurate documentation of nursing care provided to ensure the effective integration of information for use by the health care team to ensure on-going and continued quality of care, in accordance with evidence-based practice, State and Federal regulations, Vermont State Board of Nursing and VNAHSR policies and regulations. 10. Follows agency protocol with McKesson processes, including but not limited to, locking-down visits, follow-up notes, visit completion, etc. 11. Performs patient and care giver education to ensure informed patient decisions can be made, including, but not limited to, medication side effects, treatment options, discharge instructions, reportable conditions, ranges of services, etc. in accordance with State and Federal regulations, Vermont State Board of Nursing and VNAHSR policies and procedures. 12. Appropriately identifies inter-disciplinary needs of the patient and documents patient needs accordingly, including, but not limited to physical therapy, social work, etc. Takes action to communicate documented information to other disciplines in a timely manner. 13. Accurately and completely fills out a variety of Agency, State and Federal forms, including but not limited to, HHABN, Medicare Notice of Non-Coverage, etc. in a timely manner. Takes action to ensure that forms are readily available during visits to facilitate timely completion. 14. Carries out visits in a time effective manner. Takes action to ensure that supervisory visits are not combined with routine visits whenever necessary. Takes action to communicate information to the Scheduler in a timely manner. 15 Assesses patients needs for HCA services, develops and coordinates POC with patient/care giver, and provides on-going supervision in accordance with State and Federal regulations. 16. As necessary, transmits patient incidents reports (infections, injuries, etc) to QI Specialist in a timely manner. 17. Coordinates safe patient discharges and/or transfers (or upon knowledge of) and ensures all appropriate paperwork and patient information is processed in accordance with department policies and procedures, and State and Federal regulations. 18. Coordinates a wide variety of patient care with physicians, providers, team members, vendors, etc. in support of the recommended plan of care to ensure safe and effective patient and family care, in accordance with evidence-based practice, Vermont State Board of Nursing and VNAHSR policies and regulations. 19. Fulfills agency responsibility to participate in monthly peer review audits. Provides constructive feedback and openly accepts feedback in a professional manner. 20. Proactively schedules, coordinates, and facilitates case conferences with Manager and team members to maximize effective communication with team members. Ensures effective and timely documentation of meeting is maintained. 21. Pro-actively advocates for patient care issues to ensure that overall quality and type of care is sensitive to each specific patient/family s needs. 22. Utilizing the nursing process, carries out comprehensive assessment of patient/care giver needs in order to provide qualitycare to assigned patients. 23. Actively participates in IDT meetings to develop an appropriate individualized plan of care within five days of admission,and every fifteen days subsequently, carries out comprehensive assessment with other members of the IDT of patient needs. 24. Stays up-to-date on a variety of pain control, symptom management, High-Tech skills; IV use and maintenance, woundVAC, complex wound care, etc. Takes action to ensure that infection control standards re maintained throughout plan ofcare. 25. Performs patient and care giver education to ensure informed patient decisions can be made, including, but not limitedto, medication side effects, treatment options, discharge instructions, reportable conditions, ranges of services, etc.. 26. Coordinates a wide variety of patient care with physicians, providers, team members, vendors, etc. in support of therecommended plan of care to ensure safe and effective patient and family care.

Shift: M-F 8am-4pm with some weekend and on call required

Specialty Type: Nursing

Sub Specialties: Home Health RN, Hospice RN

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