Essential Functions and Responsibilities:
Provide individualized nursing care as needed in accordance with the Individualized Service Plan (ISP) or Person-Directed Plan (PDP) and current nursing standards of care, including but not limited to administering and monitoring medications for efficacy, adverse effects, precautions, contraindications and potential interactions with other medications as well as monitoring vital signs and the overall health status of the consumers.
Perform procedures as ordered by the physician and by in accordance with state law and standard nursing practices.
Maintain medical records to reflect timely, accurate, legible, and complete documentation.
Communicate as needed with families, conservators, guardians, case service managers, service coordinators, direct care staff, nurses, physicians and other medical, counseling and therapeutic professionals to ensure the coordination of nursing care.
Provide training as needed to consumers, staff, family members, guardians or other significant persons based on the consumer's individual needs, including but not limited to training on their special needs, diagnoses, medications, treatment, nutritional requirements, medical and adaptive equipment and other health related issues.
Perform and document comprehensive assessments of consumers in a timely manner upon initial enrollment, as well as annually and as needed thereafter to determine the individualized health needs of each consumer.
Document and report any and all significant concerns or changes in consumers' health condition to the proper personnel.
Ensure the timely completion of all required nursing documentation including but not limited to billable and non-billable nursing logs, as well as information required to be entered and updated electronically into the company database.
Ensure that all medical and adaptive equipment continue to be appropriate and are in safe working order, reporting any and all defects immediately to appropriate administrative staff.
Ensure that all medical and therapy appointments are scheduled and completed as needed.
Ensure that all staff, family members, or other persons in contact with the consumer receive instructions to prevent the spread of infectious diseases.
Perform all job duties in adherence to state and federal laws concerning confidentiality, including HIPAA Privacy Laws.
Ensure that all physician orders are current for all medications and treatments.
Ensure that all medications, treatments, and therapies are performed and received in a timely manner according to current regulations and applicable standards.
Ensure that all Medication Administration Records (\u0022MARS\u0022) are current, correct, and properly completed by all staff.
Review all post hospital orders and records and insure consumer medical records are updated accordingly.
Ensure all medications are labeled, stored, and secured properly according to current standards and guidelines.
Weekly billing average at 27 hours.
Degree from an accredited school of nursing.
Current licensure in the State of Texas.
12-18 months of clinical practice required.
One year of experience working with individuals with developmental disabilities/mental retardation, or in a related field, preferred.
Must be at least 18 years of age.
Must possess a valid driver license with a good driving record, if applicable.
Must be 25 years of age to transport consumers unless otherwise authorized.
Must be able to effectively communicate (read, write, and understand) in English.
Must have good record keeping skills.
Criminal history must meet or exceed company standards at the time of hire and be maintained at this level throughout employment.