DUTIES & RESPONSIBILITIES Patient Care Develops a written plan of care for each patient on caseload; Updates and initiates the plan of care and assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any), and caregiver(s); Assesses patient’s condition, initiates plan of care, re-evaluates and updates as necessary. Initiates proper nursing procedures and provides services that are ordered by the physician as indicated in the plan of care; Provides skilled nursing care; Provides patient, caregiver, and family counseling; Provides patient and caregiver education; Prepares clinical notes; Communicates with the physician who is responsible for the plan of care and other health care practitioners (as appropriate) related to the current plan of care. Obtains all necessary physician orders and collaborates with physician as patient’s needs dictate. 75% of all charting to be done in the patient’s home. Attends case conferences to discuss multidisciplinary team responsibilities, patient progress, plans for continued care, new problems, etc. Re-evaluates the need for continued care on an ongoing basis; initiates recertification as necessary. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient. Prepares clinical notes and updates the primary physician when necessary and at least every sixty days. Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required. Communicates with community health related persons to coordinate the care plan. Additional Duties Participating in the HHA's quality assessment and performance improvement program and HHA-sponsored in-service training. Participates in holiday rotation and on-call duties as defined by the on-call policy. Ensures that arrangements for equipment and other necessary items and services are available. Instructs, supervises and evaluates home health aide care and LPN care provided every two (2) weeks per state and agency regulations. Supervises Licensed Practical Nurses (LPNs)/ Licensed Vocational Nurses (LVNs) and/or Home Health Aids (HHAs)/Certified Nursing Assistants (CNAs), as directed. Participates in all mandatory meetings, training, and in-service education. Must participate in the on call/visit holiday rotation as required by the agency. All weekend/holiday visit documentation must be completed by the following business day by 8:00 AM. The above statements are only meant to be a representative summary of the major duties and responsibilities performed by the employee of this job. The employee may be requested to perform job-related tasks other than those stated in this description. The employer for this position is stated in the job posting. The Pennant Group, Inc. is a holding company of independent operating subsidiaries that provide healthcare services through home health and hospice agencies and senior living communities located throughout the US. Each of these businesses is operated by a separate, independent operating subsidiary that has its own management, employees and assets. More information about The Pennant Group, Inc. is available at http://www.pennantgroup.com. We are proud to offer a wide range of comprehensive services to meet the needs of our adult patients. Our team of professional caregivers specialize in providing personalized medical care and rehabilitative therapy. We are an equal opportunity employer committed to ensuring that all conditions and privileges of employment, including recruitment, hiring, evaluation, transfer, promotion, discipline, determination of compensation and/or benefits, and termination of employment, for all job classifications, are based on qualifications and work record. No employment decision is made, nor do we discriminate, on the basis of race, color, religion, creed, sex/pregnancy, sexual orientation, gender identity, gender expression, age, national origin, ancestry, citizenship, veteran status, or disability.