Basic Summary of Position: Provides direct care and case management for a team of Agency clients in accordance with the state Nurse Practice Act and Agency policy. Directs assigned team members, i.e., Home Health Aides.
1. Reviews client referral information and responds to requests and inquiries as appropriate.
a. Collaborates with clinical supervisor regarding the eligibility and appropriateness of client for home care services.
b. Completes comprehensive assessments including OASIS data set within forty-eight (48) hours of referral or by other physician-ordered date.
c. Determines appropriateness of referral for home care services during initial visit and responds per Agency policy and standard guidelines.
2. Performs initial and ongoing client assessments based on Agency policy and standards of practice to ensure effective and appropriate home care services.
a. Performs comprehensive assessments including OASIS data collection where indicated.
b. Considers the physical, psychological, and socioeconomic needs of the client, the level of family acceptance, and the ability for client needs to be met in the home.
c. Collaborates with physicians, other health care professionals (therapists, social services, home health aides), clients, and families in developing a comprehensive, coordinated plan for care.
d. Follows Agency guidelines for completion of all forms, including consents, 485 Plan of Care, orders, care plans, HHA care plans, Medication profiles, etc. within 48 hours from visit—including all Communication Notes and coordination.
3. Directs, plans, and initiates appropriate action independently and responsively in home care situations.
a. Identifies and assesses overt and subtle signs of impending physiologic and psychological changes. Reports significant changes in client’s condition to physician in a timely manner consistent with client needs.
b. Makes decisions and/or recommendations reflecting consideration of immediate and long-range effects (frequency of visits, components of care plan, additional services)
c. Confers with the clinical supervisor on a regular basis. Utilizes agency and community resources appropriately.
d. Monitors documentation of clinical records to ensure compliance with regulatory standards of timeliness, accuracy, and completeness.
e. Provides on-call support for clients per schedule.
f. Communicates with other disciplines/departments when required.
4. Manages Home Health Aides to provide effective and quality home care services.
a. Identifies the educational needs of team members. Provides training or refers to clinical supervisor to arrange specific training program. Provides or recommends educational resources.
b. Performs or delegates in-home supervision of team members.
c. Identifies staffing needs and communicates this information.
d. Collaborates with supervisors to identify staffing needs and evaluate qualifications and competencies of current and new employees.
5. Promotes personal safety and a safe environment for clients and coworkers.
a. Demonstrates knowledge of safety infection control practices by compliance with policies and procedures.
b. Recognizes and responds appropriately to potentially unsafe situations.
c. Demonstrates safe and competent practice in the use of equipment.
d. Assesses safety of environment and takes initiative to prevent accidents and promote safety.
e. Participates in all mandatory education per established guidelines.
6. Performs job duties in accordance with Agency policies, procedures, and professional and community standards.
a. Maintains confidentiality in all aspects of the job. Does not reveal information from client records to others, except as identified in Agency policy. Secures written confidential documents in a manner that prevents unauthorized release.
b. Participates in the development, implementation, and evaluation of the Quality Improvement Program and activities.
c. Provides care in accordance with state and federal regulations.
d. Follows established Agency guidelines for protection of confidentiality of all written and computer files.
e. Protects personal password in accessing client and/or personnel files
7. The ability to maintain friendly, cordial relations with all clients and employees.
8. The ability to maintain friendly, cordial relations with all clients and employees; maintain a positive work atmosphere by acting and communicating in a manner that results in a positive work relationship with customers, co-workers and managers.
9. Ability to comply with ATI standards of operations.
10. Ability to adhere to the Core Values of the Company.