RN, Registered Nurse, Home Health

📋 Description

• • Assess patient eligibility and needs for home health services through comprehensive evaluations, considering cultural, psychological, functional, cognitive, and social determinants.
• • Develop, implement, and revise individualized, patient-centered plans of care aligned with patient goals, preferences, and physician orders.
• • Deliver nursing care directly in patients' homes, ensuring adherence to agency policies, clinical standards, and safety protocols.
• • Coordinate care with physicians, therapists, home health aides, and other healthcare professionals to ensure continuity and comprehensive patient support.
• • Conduct supervisory visits for Home Health Aides at least every 14 days, documenting assessments of patient needs and aide performance.
• • Review all patient medications to identify potential adverse effects, drug interactions, duplicate therapies, non-compliance, and ineffective treatments, maintaining an updated medication list in the home.
• • Communicate medication concerns promptly to the healthcare team and initiate appropriate interventions.
• • Educate patients and caregivers on disease management, emergency procedures, safety practices, and home care techniques to promote independence and timely discharge.
• • Accurately document all patient care activities, assessments, interventions, and progress in the electronic medical record (EMR) using correct medical terminology and abbreviations.
• • Organize and prioritize case management responsibilities, including complex clinical tasks, while meeting productivity standards and time constraints.
• • Identify ongoing patient needs and initiate timely referrals to appropriate services or specialists as required by the plan of care.
• • Utilize clinical judgment to respond to changes in patient status and adjust care plans accordingly within agency guidelines.
• • Ensure compliance with the agency’s Home Health Infection Control Plan and adhere to all infection prevention policies and practices.
• • Participate in SHP analysis, PDGM case conferencing, one-on-one case conferencing, QA initiatives, and QAPI programs to support agency quality and regulatory goals.
• • Make timely and accurate updates to QA/SHP documentation and modify clinical practices to meet established performance thresholds.
• • Maintain reliable transportation and a motor vehicle record that meets Saint Francis Health System guidelines for daily home visits across the service area.
• • Support interdisciplinary team collaboration and assist with the orientation of new staff as directed by leadership.
• • Comply with all federal, state, and institutional regulations governing home health nursing practice.
• • Recognize this role as a safety-sensitive position under Oklahoma law, requiring adherence to drug-free workplace policies, including refusal to hire or disciplinary action for positive marijuana tests, even with a valid medical license.