RN Home Health​/Hospice - SMH

• Job Category Registered Nurse, Home Health/Hospice
• Employee Type Full-Time

Through competent application of the nursing process, provides and directs the provision of home nursing care based on Northeastern Health System - Sequoyah Home Health policies and procedures. Directly supervises Home Health Aides assigned to the same patients.

• Maintains established departmental policies and procedures, objectives, quality assurance programs, safety, environmental and infection control standards.
• Provides those services requiring substantial and specialized nursing skill in accordance with the plan of treatment signed by the physician, and makes the initial evaluation visit to the patient.
• Accepts only patients referred by the HH Coordinator or designee.
• Demonstrates competency in all skills required for the Northeastern Health System - Sequoyah Home Health including but not limited to venipuncture, infusion therapy, infusion therapy device care, and wound/ostomy care.
• Evaluates and regularly re-evaluates the nursing needs of the patient; initiates, develops, implements and makes necessary revisions of the patient's plan of care.
• Assesses patient's continual care needs. Plan of care addresses all problems identified in the assessment or provides evidence of a rationale for not doing so.
• Initiates diagnostic, preventive and rehabilitative nursing procedures as appropriate to the patient's care and safety.
• Makes referrals to other disciplines as indicated by the needs of the patient or documents rationale for not doing so.
• Observes signs and symptoms and reports to the physician and/or other appropriate health professionals as often as needed, changes in the patient's condition.
• Teaches, supervises and counsels patient and family regarding home nursing procedures and other care needs as appropriate to the patient's condition. Utilizes Northeastern Health System - Sequoyah Home Health educational material as appropriate.
• Coordinates the total plan of care and maintains continuity of patient care by liaison with other health professionals assigned to the same patients as the nurse. Attends patient care conferences.
• Participates in all aspects of care, including an ongoing multidisciplinary evaluation and development of the plan of care. Initiates patient care conferences for complex and/or multi-disciplinary patients whenever needed or helpful to ensure good coordination of care.
• Supervises and teaches home health aide every two weeks, assesses patient's need for unskilled care and revises plan of care as appropriate. Communicates plan of care changes to aide and scheduler as often necessary.
• Develops, prepares and maintains individualized patient care progress records with accuracy, timeliness and according to policies. Submits accurate documentation within 24 hours of visit.
• Is responsible for following all policies and procedures of Northeastern Health System - Sequoyah Home Health regarding service delivery, documentation, and care coordination. During supervisory visits, exhibits full compliance and verbalizes knowledge of Northeastern Health System - Sequoyah Home Health policies, including but not limited to patient education, infection control, management of hazardous wastes, and age-specific behaviors for patients.
• Actively participates and is involved in Northeastern Health System - Sequoyah Home Health quality assessment and performance improvement program. Can verbalize own responsibilities and activities.
• Is competent in OASIS data collection and Medicare requirements of summaries (i.e. 60D, Transfer, D/C, PHR), orders for frequency and duration; covered services and supplies; homebound status, admission and discharge criteria.
• Is competent in the use of PTCT software for documentation of travel, visit notes, care planning, admissions, and physician prescriptions; and the use of a modem for updating patient information.
• Completes work, care and documentation with accuracy and within Northeastern Health System - Sequoyah Home Health time frames.
• Maintains compliance with all laws, regulations and policies.
• Demonstrates the initiative to meet the needs of the Northeastern Health…