Essential Functions

1. Receives the intake referral information and prepares paperwork/tools necessary for the visit.

2. Obtains all pertinent medical history from client, family or significant others.

3. Performs home safety check and environmental assessment of the client’s home environment.

4. Performs the socio-psychological evaluation of the support systems available to the client and documents necessary emergency contacts etc.

5. Performs assessment visit and documents accordingly (i.e. OASIS/ Skilled Nursing Note etc.).

6. Performs physical examination and review of all body systems and documents such accordingly.

7. Develops an appropriate and effective Plan of Care (POC) to be submitted to the physician for approval and implementation.

8. Determines medical necessity for other services that could enhance the positive outcome desirable for the case.

9. Evaluated the client’s ADL and IADL abilities and therefore need of support services such as home health aide.

10. Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan the beginning of each certification period.

11. Supervises the HHA every 2 weeks (in accordance with state/federal requirements) and documents the supervision without having to be directed to do so.

12. Orders “other” professional services that are effective and is willing adjust frequency of these services as outcome progresses and the client’s condition warrants.

13. Reviews billing processes with client and/or family advising client and/or family when co-pay or Medicare is not likely to pay for services (ABN). 

14. Effectively communicates with client and family the POC and progression of such. Keeps the client informed ongoing.

15. All initial paperwork (including Start of Care) completed within 5 days from date of initial visit.

16. All med orders or med changes submitted to agency approved software within 24 hours.

17. All patient care notes submitted with 48 hours of nursing visit.

18. All nurses must see 95% of their patients 95 % of the time.

19. All paperwork necessary for discharging patients from the agency completed and submitted to agency approved software within 48 hours.

20. All resumption of Care must be completed by RN every 60 days and submitted within 48 hours via agency approved software.