RN, Home Health

Establish and utilize the plan of care to implement and direct patient care (the plan of care is updated at least monthly and also as changes occur); progress notes should reflect utilization of the care planRecognize the patient and family as the unit of careInform the patient's insurance case manager via the Managed Care Liaison about the ordered visit frequency plan(s) for patient care and patient's statusProvide clinical supervision of the hospice home care teamHome Health Aide (HHA) care plans must be reviewed and / or updated with each onsite visit and initialed; the original is kept on the chart and staff are responsible for weekly updatesPerform HHA onsite supervisory visits every 14 days according to Medicare guidelines, and conduct an onsite with the HHA during the first week after start of carePerforms all aspects of the skilled nurse home visit : Plan and prepare for the visitPerform skilled interventions including teaching, pain management, and symptom controlReport changes in patient condition or other pertinent data to physician as neededComply with established SN frequency as per form 485; change frequency as needed according to physician ordersDocument assessment of patient's status and response to skilled intervention and teaching on hospice SN progress noteDocument ongoing discharge planning from start of care, and prepare discharge summary according to agency policyEnsure that documentation shows subsequent planned visits with patientReport unexpected changes in patient condition or other pertinent data to the physician according to agency policyProvide appropriate support at the time of death and during the period of bereavementUtilize supply requisition process in an appropriate and cost effective mannerInform the Managed Care Liaison of patient updates regarding care, status, and frequency of visits for all disciplinesTeach the patient / family about care needs, disease process, and health maintenance measuresEnsure documentation on the hospice SN progress notes reflect patient / caregiver response to skilled instruction or treatment, as well as an update of status / problemsProvide skilled instructions according to the nursing plan of care and any teaching guides (as applicable)Teach and counsel patient, family, or other primary caregiver regarding expected disease progression, care techniques, and other health measuresEnsure that the patient's medical record reflects that the patient and caregiver are included in the planning and rendering of care as evidenced by patient / family response to plan of care / intervention / instructionsRemain knowledgeable regarding current hospice trends and insurance issuesParticipate in joint visits with the Hospice PCC, PRN, and / or designee at least annuallySeek attending physician, hospice medical director, or hospice PCC intervention and follow up appropriatelyMaintain current update of clinical skills and recognize / report skills review needs to the Hospice PCCDemonstrate courtesy, compassion, tact, patience, and respect for patients, families, and co-workersPractice hospice nursing with utilization of appropriate palliative tools (i.e. open communication, empathy, acceptance of spiritual and cultural differences, ability to assess and manage caregiver needs / problems, accurate pain assessment and treatment, teaching the family the normal processes of the human body as death approaches, and understanding of stages of grief and bereavement)Recognize and assume patient / family advocacy roleCall the Team Assistant's voice mail each morning with daily plans and changesDocument all patient care in reimbursable and professional terminology as evidenced by audit reviewThe Nursing Plan of Care and any teaching guides used must be on the patient's clinical record within the first week from start of careThe Plan of care is to be utilized with planning SN visits and updated accordinglyMedication profiles will have classification completed and on the patient's medical record within the first week of start of care; medication profiles must be updated once per month and / or with additions or changes and signed / datedDischarge summaries are due within 48 hours after the patient is discharged from service and are to be submitted to the Hospice PCCAdmission paperwork and orders must be completed within 48 hours and are to be submitted to the PCCRecertification's are due three (3) weeks prior to the end of the current certification period, and must be submitted to the PCC for reviewPhone orders are to be submitted for processing within 48 hours after receiving the orderQCC reports are to be completed by the involved staff person within 24 hours and are to be submitted to the PCCWeekly schedules are to be submitted to the Hospice PCC and Team Assistant on Thursday for the coming weekPayroll sheets with SN progress notes are to be submitted every Monday, Wednesday, and Friday by 8 : 00 AM; exceptions for holidays will be determinedNursing staff will perform billing audits and chart audits monthly as directed by the PCCEducation and ExperienceMinimum Education : Successful completion of an accredited Registered Nursing ProgramPreferred Education : Bachelor of Science in Nursing (BSN)Experience : One (1) or more years' prior med-surg experience is requiredCertificates, Licenses, RegistrationsApplicant must be licensed to work as a Registered Nurse in the Commonwealth of Virginia and must hold a current BLS certification. CHPN certification is preferred.