HOME HEALTH RN; Hospice

Home Health RN (Hospice)

Qualifications:

Responsibilities include but are not limited to:

Patient Care and Oversight of the Plan of Care:

• Manage and prioritize patient caseloads in accordance with physician orders and care plans
• Perform comprehensive skilled assessments, including OASIS, to determine care needs and service eligibility
• Develop, implement, and update individualized, patient-centered plans of care
• Coordinate admissions, interdisciplinary services, and care delivery across the healthcare team
• Deliver high-quality, compassionate skilled nursing care
• Ensure patient safety, emergency preparedness, and prevention of re-hospitalization
• Maintain regulatory, legal, and ethical compliance, including Medicare Conditions of Participation
• Complete and maintain accurate, timely electronic clinical documentation
• Communicate changes in patient condition and coordinate interventions promptly
• Facilitate care coordination, case management, and discharge planning
• Participate in interdisciplinary case reviews and outcome evaluations
• Promote patient and family education, independence, and engagement

Medications:

• Provide oversight and ensure the safe administration of medications at admission and during each patient visit
• Identify and reconcile all prescribed and over-the-counter medications, allergies, and supplements, and document accurately in the physician's plan of care
• Review potential medication side effects, interactions, and contraindications; provide education to patients and caregivers
• Establish and implement individualized medication administration systems to support patient safety and adherence
• Accurately document medication pre-pouring, including drug name, dosage, frequency, dates, and times when applicable
• Educate patients and families on medication purpose, administration, interactions, side effects, adverse reactions, and appropriate follow-up actions
• Monitor and evaluate medication effectiveness, communicate changes to the physician, and document outcomes in the medical record

Supervision:

• Supervises Licensed Practical Nurses (LPNs) and Paraprofessionals providing care.
• Develops and updates individualized Homemaker/Companion/HHA plan of care for each patient, including all aspects of care, diagnoses, potential drug interactions/side effects, action in emergencies, etc. and enters into telephony system
• Supervises HHAs in the provision of care to assure safe implementation of the plan of care and as required by regulation.
• Mentors staff (nurses and paraprofessionals) and participates in their orientation as assigned

Documentation:

• Maintain accurate, timely, and complete clinical documentation for each patient visit, including assessments, care provided, and plans of care
• Document patient and family education, instructional materials provided, return demonstrations, and patient response
• Complete all required documentation in accordance with agency policies and guidelines
• Record communications with external agencies and insurance providers
• Prepare and submit required 10-day, 60-day, and discharge summaries
• Ensure documentation complies with CHAP standards, reimbursement requirements, and applicable regulatory guidelines

Team:

• Collaborate with interdisciplinary team members to support coordinated, patient-centered care
• Provide clinical expertise and support to team members as needed
• Participate in required team, clinical staff, and case conferences
• Coordinate care across disciplines to ensure integrated plans of care
• Partner with intake, scheduling, and liaison staff to ensure timely admissions and care transitions
• Coordinate with liaison nurse during hospital or facility stays
• Participate in weekend and holiday coverage in accordance with agency requirements

Educational:

• Certified in CPR
• Attends yearly OSHA in-service and completes annual skills validation
• Identifies knowledge gaps and remedies this independently
• Attends minimum 12 hours of in-services per year, including 6 hours of hospice inservice for staff caring for hospice patients
• Shares information with other Agency personnel

Billing:

• With Intake and Billing, explores all billing sources available to the patient
• Writes/communicates billing instructions to billing and other departments
• Communicates with insurance case managers according to processes of each company to assure authorizations and payment for services. Follows guidelines for the provision of care under Medicare and Medicaid
• Participates in pre-billing review as needed or assigned

All Agency Employees Must:

• Abide by HIPAA privacy practice guidelines
• Abide by related agency policies and appropriate departmental procedures
• Other duties and responsibilities as may be required by the agency