Job Summary:  Plans, organizes and directs home care services and is experienced in nursing with an emphasis on community health education/experience.  Builds from resources in the community to plan and direct services to meet the needs of the individual and families within their homes and communities.

Demonstrates proficient assessment skills for admission, transfer, reassessment and the discharge of clients.  Demonstrates sound clinical judgment and excellent clinical skills.  Coordinates, and supervises caregivers in the delivery of client care.  Maintain compliance with Agency policies, procedures including federal state and local regulations.

Qualifications:

Graduate of an accredited school of nursing.  One to two years of recent acute care experience in an institutional or home care setting.

Current New York State RN License, CPR certification and valid driver's license

Bachelor's degree preferred, with one year of home care experience

Management experience not required.  Responsible for instructing and directing HHA's, PCA's and companions

Excellent observation, verbal and written communication skills, problem solving skills, basic math skills and nursing skills per competency checklist

Works collaboratively with clients, families and staff

One year of supervisory experience preferred

Responsibilities/essential functions:

Complies with HIPPA, federal state and local regulations and safeguards all client related information

Performs the initial comprehensive client assessment, initiates the care plan and re-assess the client's need and progress on an on-going basis

Involves the client/family in developing the plan of care, caregiver care plan/instructions

Develops and initiates the care plan to be aligned with services provided that meets the client needs and preferences

Initiates the plan of care under the physician or legally authorize practitioner orders as indicated to provide nursing services

Notifies physician or legally authorized practitioner and all care staff of change in client's condition and revise care plan as needed

Update the plan of car and care plan when there is a significant health status change in the client/patient's condition

Educate, coach and monitor client/patient and family including caregivers on medications and treatments to ensure client's needs are met

Completes and submits assessments, re-assessments, transfers and discharges in accordance with agency defined time frames

Conducts and documents competency and training of direct care staff to ensure safe quality care is provided to clients and adhered to Agency policies 

Delegate tasks to caregivers according to established standards, skill level required and ability to perform task to achieve desired outcome 

Manages, supervises and monitors direct care staff to ensure care meets clients needs, preferences and compliance to Agency policy and procedure

Performs supervisory visits and monitor the outcomes

Documents and updates the clinical record according to policies and procedures to meet regulatory standards

Prepares discharge/transfer summaries which reflect the care provided and outcomes including educating staff and client family on infection protocols

Demonstrates sound judgement and decision making skills throughout work assignments

Assist the Administrator with quarterly clinical chart review to meet regulatory standards

Immediately reports to Supervisor any client incidents and/or complaints and completes documentation on an Incident Report

Appearance and attire is appropriate and in accordance withAgency policy

Maintains acceptable attendance status

Physical Elements

Sufficient clarity of speech and hearing or other communication, capabilities, with or without reasonable accommodation, to enable the employee to communicate effectively.

Sufficient vision or other powers of observation, with or without reasonable accommodation, to enable employee to review a wide variety of materials in electronic or hard copy form

Sufficient manual dexterity, with or without reasonable accommodation, to enable the employee to operate a personal computer, telephone, and other related equipment.

Sufficient personal mobility and physical reflexes, with or without reasonable accommodation, to enable the employee to safely lift, move, or maneuver whatever may be necessary to successfully perform the duties of their position; function in a general office and frequent travel to a variety of field sites.

Environmental Elements

Office noise level varies, controlled temperature conditions and no direct exposure to hazardous physical substances.

travel to a variety of client homes and perform in conditions that vary greatly depending upon the client's home environment.