Position reports to Clinical Manager and has responsibility to ensure proper services are provided to all patients serviced under their care. Responsible for supervision, evaluations and instructions provided to caregiver staff as well as patient assessments according to acceptable standards of practice for a registered nurse.
DUTIES AND RESPONSIBILITIES:
1. Complete and submits initial assessment that includes a medical history, particularly as it relates to the present condition, from the patient and/or family member(s); completes a systems review (neuro, respiratory, GI, GU, etc.) including vital signs, assessment of psychosocial, mental status, and pain assessment as well as an evaluation of the patient’s nutritional status (diet) and functional status. The assessment should also include a home safety review and development of an emergency disaster plan. Ongoing assessments are completed per Company Policy and State/Federal Regulations.
2. Evaluate and document the patient, family member(s) and home situation to determine what health teaching will be required; evaluates and documents assessment of the patient’s environment to determine what assistance will be available from family members in caring for the patient.
3. Evaluate and document the patient’s condition and home situation to determine services required by the patient and the frequency of this service. Includes the patient/family in care planning as indicated; develops and implements the nursing care plan (for skilled cases) and/or Personal Care Plan (for non-skilled or in addition to skilled services where appropriate).
4. Develop plan of care for in conjunction with the patient and based on the initial assessment; orients each caregiver to the Plan of Care. Re-evaluates the Plan of Care at required intervals and as appropriate and necessary. Supervises and evaluates the care provided by all staff as required by Company Policy and State/Federal Regulations, payer and accreditation standards.
5. On a weekly basis submits written documentation of the employee and/or case supervision, and visit notes. Clinical Supervisor PD 08-09 Page 2
6. Complete all required documentation accurately and appropriately and in a timely fashion. Addresses issues with the Clinical Manager, concerning the patients, and works cooperatively to reach resolution.
7. Discuss with the Clinical Manager the need for involvement of other members of the health team such as the physical therapist, speech therapist, occupational therapist, social worker, etc.
8. Ensure professional development by attending continuing education, and active participation in professional and related organizations as well as individual research and reading; maintains an on-going knowledge of current drug therapy. Attends/completes annual educational requirements stipulated by Company policy and or state/federal regulations.
9. Exercise good judgment when notifying physician and clinical manager of changes in patient’s condition; conducts appropriate follow up with management. Demonstrates proper critical thinking when dealing with difficult patients and or clinical situations
10. Maintain confidentiality regarding all aspects of patients and/or employee information in compliance with HIPAA rules. Maintain compliance with applicable state and federal regulations, company policies/procedures and accreditation standards.
11. Other duties as assigned.
IV. SUPERVISION & MANAGEMENT RESPONSIBILITY:
Has supervisory responsibility for field staff, including certified home health aides and professional staff in specified region/territory.
Conducted annually by Manager