• Accountable that medications and treatments are administered to assigned clients.
• Assess the client to establish the client's plan of care.
• Re-evaluate the plan of care to determine client is still eligible for services.
• Provides care in accordance with agency policy, local, state and federal laws and plan of care. 
• Supervises, provides training and evaluates home care aides.
• Accompanies home care aides on supervisory visits with clients.
• Safeguards clients’ property. 
• Maintains clients’ self-esteem, privacy and confidentiality of personal information.
• Complies with HIPAA guidelines. 

Skills: Medication Management, Client Assessment, Care Plan Review, Regulatory Compliance, Staff Supervision, Supervisory Visits, Property Safeguarding, HIPAA Compliance

• Provides clients with opportunities for independence and choice consistent with their care plans.
• Accountable that physicians’ orders are processed and physicians are notified in a timely manner.
• Directs and documents care provided to clients.
• Receives and shares information, observes and reports clients’ conditions to appropriate staff. 
• Explains procedures before and during care.
• Directs and assists with client, family / significant other education. 
• Utilizes appropriate bag techniques.
• Reports signs/ symptoms of client infections to appropriate staff in a timely manner.

Skills: Client Independence Support, Physician Order Management, Care Documentation, Condition Reporting, Procedure Explanation, Client Education, Bag Technique Utilization, Infection Reporting

• Performs initial assessment visit to develop Plan of Care that includes realistic and measurable age-appropriate patient goals in collaboration with the patient and members of the health care team. 
• Implements and evaluates the interventions identified in the medical and nursing Plans of Care and initiates necessary revisions.
• Coordinates home health aides, LPN, patient/caregiver and families in the provision of care.
• Promotes continuity of care through coordination of patient services through participation in patient care conferences with clinical managers and other healthcare members.
• Documents the delivery of care to comply with regulatory requirements, agency policy, procedures and standards of practice.
• Performs cognitive, cultural, readiness, literacy, and skills assessment of patient to develop educational plan in collaboration with patient/caregiver and members of the health care team and implements and evaluates individualized patient education plan based on age-specific criteria.
• Serves as a liaison with internal and external customers to assure effective communication. 
• Acts as a patient advocate to promote goal attainment.
• Displays time management and organizational skills.
• Demonstrates knowledge of basic and advanced cardiac diseases and treatment of patients (examples include but are not limited to cardiac/lung transplant patients, new and end-stage CHF patients, Ventricular Assist Device patients)
• Demonstrated IV competence as defined by the agency.
• Participates in mandatory services and educational activities.
• Assumes responsibility for ensuring own professional growth.
• Accountable for the utilization and practice of systems thinking, teamwork, and customer service.

Skills: Patient Assessment, Care Plan Development, Care Coordination, Documentation Compliance, Patient Education, Effective Communication, Patient Advocacy

• Provides clinical services within the scope of practice, as defined by the state laws governing the practice of nursing, in accordance with the plan of care, and in coordination with other members of the health care team.
• Makes the initial and or comprehensive nursing evaluation visit, determines primary focus of care, develops the plan of care within State-specific guidelines, and submits accurate, complete, and timely documentation, per policy.
• Regularly evaluates and re-evaluates (as warranted by changes in condition but at least every 60 days) the patient's nursing needs.
• Performs patient comprehensive assessments at designated time points and develops the appropriate POC, in collaboration with physician orders.
• Ensures patients meet home health eligibility and medical necessity guidelines as defined by the payer source.
• Initiates, develops, implements and makes necessary revisions to the plan of care in collaboration with the physician and other health care professionals involved in care.
• Makes referrals to other disciplines, as indicated by the patient's assessed need.
• Responds to outcome coordinator, coder and Patient Care Manager requests for clarification to OASIS assessments on the same day that the request for more information is sent.
• Encounters for the episode and determines needed RN encounters based on the patient's needs and regulations.
• Instructs and supervises the patient's family caregiver in the care of the patient and maintenance of a healthy environment for the patient.
• Actively participates in weekly case conferences.
• Maintains a current and accurate patient medication profile.

Skills: Clinical Service Delivery, Nursing Evaluation, Care Plan Development, Patient Assessment, Home Health Eligibility, Plan Revision, Care Coordination, Family Caregiver Training

• Assessment, report the status of the patient, assessed needs, and plan of care overview to the team leader on the same day (or by the next business day).
• Observes, records and reports to the physician and/or team leader the patient's signs and symptoms, response to treatment and changes in the patient's condition. 
• Ensures adequate Team Leader (TL) communication when physician follow-up is needed.
• Communicates changes in visit assignments, dates of scheduled visits, and schedule changes to the scheduler and Patient Care Manager to ensure patient needs are met.
• Communicates timely and effectively with agency personnel and ordering physician to process orders and OASIS data sets, schedule home visits, and deliver services to the patient as ordered by the physician and in accordance with applicable laws and regulations.
• Facilitates hand-off communication to RN and PCM who will cover patients in their absence, prior to scheduled days off.
• Performs regular and supervisory visits according to the plan of care and submits complete visit notes within 24 hours of completion visit.
• Directly and/or indirectly supervises care provided by the home health aides and licensed practical vocational nurses, provides instruction, and assigns tasks according to State and federal regulations.
• Participates in on-call rotation.
• Adheres to and participates in the agency's Episode Management process.
• Assists in the orientation of new agency personnel
• Completes client's required learning courses, additional assignments per DON request, as well as any state-specific required training per state regulation, practice act requirements.
• Participates in the performance improvement plan and process to ensure positive patient outcomes.

Skills: Patient Reporting, Observation Skills, Team Coordination, Schedule Management, Physician Liaison, Staff Supervision, Visit Documentation, Performance Improvement

• Excellent customer service skills.
• Ability to work without direct supervision.
• Excellent communication skills.
• Knowledge of nursing principles and practices.
• Knowledge of the nursing process and its applications to patient care.
• Must be able to develop skills to use the technology in a home care setting.
• Excellent documentation skills.
• A professional personal appearance makes a good first impression.
• Able to provide care appropriate to the age of patients served (adult and geriatric) patients based on principles of growth and development and life stages.
• Confidentiality regarding PHI regarding patient and co-worker information.
• Able to follow infection control and transmission-based precaution procedures.
• Critical care, oncology, or intravenous skills.

Qualifications: BS in Nursing with 1 year of Experience

• Able to hold current Registered Nurse licensure
• Able to current CPR
• Professional nursing experience in an acute care setting
• Professional nursing experience in a home care setting
• Ability to consistently demonstrate a commitment to the Mission and Organizational Code of Ethics and adhere to the Compliance Program
• Recent, verifiable clinical (medical/surgical) experience
• Ability to work independently and manage time effectively
• Must have strong interpersonal skills
• Must have solid computer skills
• Experience with electronic medical records (EMR)

Qualifications: BA in Health Administration with 2 years of Experience

• Able to unencumbered California Registered Nurse (RN) License.
• Must have current Basic Life Support (BLS)/ First Aid Certification.
• Nursing experience in a clinical setting with a frail or elderly population, preferably Home Health or Hospice.
• Excellent clinical, organizational and communication skills in settings with seniors, their families and interdisciplinary team members.
• Experience and competency working with people from diverse backgrounds.
• Deep commitment to helping unlock the potential of the most vulnerable seniors.
• Ability to work varying hours, including weekends and holidays.
• Nursing skills and knowledge base specific to the specialty.

Qualifications: BS in Public Health with 1 year of Experience

• Nursing experience in an acute care setting.
• Home health experience with thorough understanding of State, Federal and Joint Commission Home Health Agency Regulatory Standards.
• Valid Florida license as a Registered Nurse.
• Must hold Certifications - CPR.
• Intravenous therapy training and experience.
• Experience caring for terminal patients and others with life-threatening illnesses.
• Able to delegate appropriate patient care activities to other members of the home health care team.
• Responsible for professional accountability and development.

Qualifications: BS in Nursing with 3 years of Experience

• Licensed to practice as a Registered Nurse with active licenses in the state(s) in which employed and practices.
• Current experience within Home Health.
• Current BLS/BCLS Certification.
• Able to educate on and follow HIPAA regulations.
• Able to maintain strict confidentiality of client information.
• Able to follow Infection Control, Standard Precautions, and OSHA standards for the healthcare professional.
• Knowledge of regulatory standards appropriate to the position.
• Must have strong interpersonal skills.

Qualifications: BA in Healthcare Management with 2 years of Experience