1. Performs assessments of the client’s status and facilitates care when needs are identified to promote wellness, reduce complications and hospitalizations. Reports changes to physicians & supervisor. 2. Follows plan of care and protocols for skilled care needs. Manages utilization as appropriate and documents clients’ progress toward goals. 3. Teaches, supervises and counsels client and family regarding home nursing procedures and other needs appropriate to client’s condition. Documents care delivered in a comprehensive, reimbursable process using professional terminology. 4. Implements skilled nursing interventions with the participation of the client and/or family based on physician’s order and plan of care. 5. Gives complete professional report of patient’s status in case conference and serves as a liaison to other health professionals participating in the client’s care. 6. Observes client’s status and reports changes to the physician and the clinical supervisor and initiates appropriate intervention. 7. Is aware of client’s episode of care, helps to ensure clients are recerted or discharged by team RN as appropriate. 8. Completes the HHCCN and obtains signature of patient/caregiver at least 48 hours prior to DC. 9. Remains knowledgeable of Medicare regulatory guidelines to ensure agency compliance. 10. Attendance at staff meetings and in-services and performs other duties as assigned
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