Provides quality care through assessment, development, implementation and evaluation of individualized participant care plans.
- Makes home visits to assess, organize, implement and evaluate participant care and reports changes and concerns to the provider and documents appropriately.
- Reviews the order inbox in TruChart or similar software daily. Obtains, transcribes and implements physician orders timely and appropriately.
- Demonstrates appropriate knowledge and skill while performing quality care and meeting the participant specific needs, as evidenced by appropriate documentation and implementation of Pathways as needed.
- Observes and assesses for changes in clinical and/or functional status and appropriately initiates follow-up actions.
Teaches and counsels participants and caregivers as needed regarding maintenance of health and prevention of illness or complications.
- Provides appropriate education to participant and family and initiates a teaching plan as needed.
- Uses educational handouts.
- Evaluates effectiveness of teaching plan and readjusts as needed.
- Provides appropriate education to staff as evidenced by documentation of needed competencies and documentation of orientation to the care plan.
Delegates tasks appropriately and supervises, instructs and guides nursing and paraprofessional staff in providing high quality nursing services.
- Delegates tasks appropriately to the specific discipline.
- Supervises all tasks delegated.
- Educates and monitors all delegation of special circumstance tasks.
- Completes and documents aide supervisions in a timely manner.
- Responds appropriately to Aide communications in a timely manner and investigates the issues as needed.
- Includes Home Health Aides and LPN’s and/or their feedback in care planning meetings.
- Collaborates/coordinates with the Rehabilitation department for Safe Participant Handling solutions.
Contributes as a member of the PACE Interdisciplinary Team. Acts as a liaison between the participant, the family/care givers, the home care supervisor and the PACE Interdisciplinary Team.
- Attends and participates in participant care plan meetings.
- Initiates and maintains measurable goals with the IDT and Home Care Life Plans.
- Advocates for participant’s desires, wishes and needs.
- Actively participates in problem solving during team meetings.
Provides leadership among co-workers.
- Demonstrates effective communication skills while working cooperatively with Home Care staff, IDT and outside providers.
- Promotes team building by demonstrating an active role in staff meetings, orientation of staff and welcoming new staff.
- Actively participates in and demonstrates understanding of QAPI process.
- Promotes professional growth, the profession of nursing and the program, when possible, by participation in profession associations, educational conferences, volunteer activities, etc.
- Adheres to all compliance policies and procedures and regulations. Promotes, fosters and displays compliance oriented behavior in the workplace.
- Performs responsibilities according to the highest quality standards.
- Practices safety awareness, reports any possible safety/environment issues to supervisor and adheres to safety P&Ps.
- Acts as a role model by arriving on time prepared to work.
Documents in an appropriate, thorough and timely manner and in accordance with Loretto Geriatric Center Licensed Home Care Agency’s medical records policies and procedures.
- Completes all reassessment requirements for all participants by due dates.
- Documents all visits, phone calls, orders, etc. appropriately and in a timely manner.
- Follows policies related to medication administration, transcription and MAR process.
- Documents a thorough assessment of participants needs and Plan of Care every 6 months and as needed to include all regulatory items.