RN, Hrly Homecare Home Health

Chesapeake Regional Healthcare

Chesapeake, VA 23326

Posted 1 month ago

Job Description

Job Summary


+ 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 plan


+ Recognize the patient and family as the unit of care


+ Inform the patient's insurance case manager via the Managed Care Liaison about the ordered visit frequency plan(s) for patient care and patient's status


+ Provide clinical supervision of the hospice home care team


+ Home 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 updates


+ Perform 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 care


+ Performs all aspects of the skilled nurse home visit:


+ Plan and prepare for the visit


+ Perform skilled interventions including teaching, pain management, and symptom control


+ Report changes in patient condition or other pertinent data to physician as needed


+ Comply with established SN frequency as per form 485; change frequency as needed according to physician orders


+ Document assessment of patient's status and response to skilled intervention and teaching on hospice SN progress note


+ Document ongoing discharge planning from start of care, and prepare discharge summary according to agency policy


+ Ensure that documentation shows subsequent planned visits with patient


+ Report unexpected changes in patient condition or other pertinent data to the physician according to agency policy


+ Provide appropriate support at the time of death and during the period of bereavement


+ Utilize supply requisition process in an appropriate and cost effective manner


+ Inform the Managed Care Liaison of patient updates regarding care, status, and frequency of visits for all disciplines


+ Teach the patient/family about care needs, disease process, and health maintenance measures


+ Ensure documentation on the hospice SN progress notes reflect patient/caregiver response to skilled instruction or treatment, as well as an update of status/problems


+ Provide 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 measures


+ Ensure 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/instructions


+ Remain knowledgeable regarding current hospice trends and insurance issues


+ Participate in joint visits with the Hospice PCC, PRN, and/or designee at least annually


+ Seek attending physician, hospice medical director, or hospice PCC intervention and follow up appropriately


+ Maintain current update of clinical skills and recognize/report skills review needs to the Hospice PCC


+ Demonstrate courtesy, compassion, tact, patience, and respect for patients, families, and co-workers


+ Practice 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 role


+ Call the Team Assistant's voice mail each morning with daily plans and changes


+ Document all patient care in reimbursable and professional terminology as evidenced by audit review


+ The Nursing Plan of Care and any teaching guides used must be on the patient's clinical record within the first week from start of care


+ The Plan of care is to be utilized with planning SN visits and updated accordingly


+ Medication 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/dated


+ Discharge summaries are due within 48 hours after the patient is discharged from service and are to be submitted to the Hospice PCC


+ Admission paperwork and orders must be completed within 48 hours and are to be submitted to the PCC


+ Recertification’s are due three (3) weeks prior to the end of the current certification period, and must be submitted to the PCC for review


+ Phone orders are to be submitted for processing within 48 hours after receiving the order


+ QCC reports are to be completed by the involved staff person within 24 hours and are to be submitted to the PCC


+ Weekly schedules are to be submitted to the Hospice PCC and Team Assistant on Thursday for the coming week


+ Payroll sheets with SN progress notes are to be submitted every Monday, Wednesday, and Friday by 8:00 AM; exceptions for holidays will be determined


+ Nursing staff will perform billing audits and chart audits monthly as directed by the PCC


Education and Experience


Minimum Education: Successful completion of an accredited Registered Nursing Program


Preferred Education: Bachelor of Science in Nursing (BSN)


Experience: One (1) or more years’ prior med-surg experience is required


Certificates, Licenses, Registrations


Applicant 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.



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