Position Summary: Provides skilled nursing care to patients in their home, including assessment, planning, interventions, evaluating, and coordination of the home plan of care. Determines patient eligibility for home care services based on agency/Medicare/Medicaid admission criteria.

　　Principal Responsibilities:

　　Admits patients to the agency in accordance with agency admissions policy and regulatory requirements.Establishes and provides a plan of treatment for the patient based on results of the evaluation visit, client needs and physician orders. Determines the need for PT, OT, ST, MSW and HHA services.Involves the patient and family/caregivers in planning, implementation and assessment of the intervention/treatment program.Completes the Oasis Start of Care Assessment and obtains appropriate admission consents as per agency policy and regulatory requirements.Submits all admission paperwork 48 hours of the initial visit.Provides an initial verbal report to the Director of Patient Services within 24 hours of the initial visit.Demonstrates understanding of cultural issues and conducts visits in a culturally sensitive manner.Provides education to patient/family/caregivers and paraprofessional staff as appropriate, on plan of care, disease process, medications, universal precautions, infection control, nutrition, safety emergency measures, patients care and community resources.Provides written/oral instructions and educational materials to the patient as indicated.Instructs, supervises, and evaluates Home Health Aides on initial start & every fourteen days and documents the supervisory visits in the patient chart. Communicates with the Director of Patient Services every two weeks and more often as indicated for changes in patient condition, changes in treatment/meds, progress towards goals and response to treatment.In consultation with appropriates disciplines, plans for discharge of the patient taking into consideration goal achievement, and provides for appropriate follow-up or referral.Documents on an ongoing basis, services provided, and response to services/treatment and changes in status relative to the plan of care.Submits SOC/Recert assessments within 48 hours and revisits, transfers, and discharges within 24 hours of visit.Assumes responsibility for maintenance of condition of employment and continued professional growth.Conferences with all clinicians providing care every two weeks and documents conference in the patient's chart.Assists with the orientation and/or guidance of new staff members.Attends staff meetings.Makes referrals for ancillary services (long term home care services, Meals-On-Wheels, etc.).Participates in clinical record audits.Communicates with MD with any changes in condition, treatment, and/or status and documents said conversation and any MD orders received in the patient chart. Adhere to organization's standards by completing annual mandatory trainings in a timely manner on topics including - but not limited to - Sexual Harassment Prevention Training, IT Security Awareness, Compliance, OSHA, HIPAA and any other training the organization may deem necessary in regards to regulatory compliance or good business practices.Supports organization's mission by striving for excellence in all aspects of their job with a focus on positive interpersonal relationship with co-workers.Adheres to the organization's policy in regards to absenteeism and appearance

　　Job Competencies & Minimum Qualifications:

　　Current license and registration to practice as a Registered Nurse in New York State. Maintains professional licensure/certification. Graduate of an accredited school of nursing and must be a registered professional nurse with:

　　(a) a baccalaureate degree in a health or human services field; or

　　(b) two years' experience in home care.

　　Salary Range : $90,000 - $100,000 per year commensurate with experience.

　　Working Conditions/Physical Demand:

　　While performing the duties of this job, the employee may be required to sit, stoop, kneel, crouch, crawl, and climb stairs. The employee may occasionally lift and/or move up to 50 pounds and frequently stand, walk, and reach with hands and arms. The employee is required to travel in increment weather (snow and rain). While performing the duties of this job, the employee is occasionally exposed to outdoor weather conditions, risk of exposure to pathogens and unsanitary conditions in client's homes.Must be able to travel locally by public transportation to make home visits. Must have valid driver's license, car registration, and insurance if applicable to the position.

　　Qualifications

　　Education

　　Bachelors or better in Human Services or related field

　　Licenses & Certifications

　　Driver's License

　　,Registered Nurse