RN - Home Care

PACE Organization of Rhode Island•Westerly, RI

About The Position

Under the supervision of the Nursing Manager, Home Care RN responsibilities includes assessment of participant safety in the community, acute care needs, medication reconciliation, home care needs and to ensure safe transitions of care. In addition, the Home Care RN assists in creating initial and on-going care plans utilizing nursing and home care assessments and attends IDT meetings and Core Team meetings as scheduled. The Home Care RN is a vital member of the IDT. This position collaborates and coordinates care with the Team PCP and social worker on a continuous basis and works with other team members as needed. Conducts history, physical exams and functional nursing assessments of enrolled participants. Develops and/or assists in the development of care plans for new and enrolled participants, provides nursing care and service to participants per plan of care and makes recommendations to IDT for services needed. Assists participants in maintaining optimum health; utilizes the standard of care tools, provides health education, and counseling to participants and caregivers facing chronic conditions and end of life issues. Triage any incoming phone calls from participant’s families or participants who call with questions or to report illness or concern. Makes appropriate referrals or treats within the scope of practice. Facilitates safe transitions of care ensuring medications are reconciled, home services are reinstated or requested, coordinates care with IDT members as appropriate Engages in problem solving on a RN/clinical level. Communicates with families regarding delivery of services and changes in orders that will impact care. Completes documentation of all nursing care and services in medical record. Records all nursing encounters per PACE documentation standards. Completes assigned care plan assessments before the care plan (CP); completes CP assessment documentation before or on the day of the CP; updates CP before the CP meeting; completes CP interventions and links a note before current CP is closed; reviews CP within 2 weeks after the CP meeting. Works with the Home Care Scheduler to coordinate and evaluate home services to maintain appropriate scheduling to meet the medical needs of the participant as evaluated using the Home Care Needs Assessment and IDT recommendations. Completes the Home Services Plan of Care for the CNA/HMK for the initial care plan and updates plan every 6 months or during a change of status. Assists Home Care Department on oversight/adherence to policy, competencies and training of CNA’s. Provides communication and problem solving to vendors with clinical/nursing issues. Conducts quarterly home health aide (CNA) observation visits of PACE employees providing personal care in the home. Provides ongoing direction and teaching to CNAs and evaluates their care and service delivery to ensure it meets PACE standards. Assists with orientation of new nursing staff and serves as a mentor to nursing students. Adheres to infectious disease and PPE standards of practice. Is knowledgeable and adheres to all nursing policies and procedures regarding standards of care. Can identify appropriate resources when unsure of specific policies or procedures. Attends staff meetings and in-services as required. Protects privacy and maintains confidentiality of sensitive participant, employee, and agency information. Performs related duties as assigned including covering the Day Center RN position PRN. Required to work weekends and holidays on a rotating basis as scheduled to deliver 24-hour care to enrolled participants.

Requirements

Ability to maintain confidentiality
Dependable and punctual with ability to maintain consistent attendance
Ability to read, write and comprehend English
Ability to maintain sound judgement under stress and communicate effectively
Ability to proficiently perform clinical/skilled tasks associated within scope of position
Proficiency with MS Office Suite or similar software
Associate's Degree, Required
Physical ability to regularly stoop, bend, kneel, lift, stand, walk, stretch and reach for extended periods of time.
Must be able to regularly lift objects up to 25 pounds and at times up to 35 pounds.
Must be able to assist a 200-250 lb participant, using proper body mechanics.
Must have hearing and vision abilities within normal range (corrected) to drive safely and/or to observe and communicate with participants.
Must be able to navigate various departments of the organization's physical premises as well as related community care settings.
Must be able to tolerate conditions typically associated within a medical office and/or home care setting including potential exposure to bloodborne pathogens and infectious diseases.
Must be able to complete assignments in variable weather conditions and ever-changing and sometimes allergenic environments in participant homes, including extreme heat, humidity, dust, smoke, pet contamination, and cleaning supplies.
Rhode Island Registered Nurse License (RN)
CPR Certification
Driver's License & access to reliable transportation; community-based travel required.

Nice To Haves

Bachelor's Degree Preferred
2 Years of direct service work (Adult Day, Nursing Home or Home Care), Preferred
1 Year of experience in a Medical or Geriatric Care setting, Preferred
1 year of experience working with a frail or elderly population, Preferred

Responsibilities

assessment of participant safety in the community
acute care needs
medication reconciliation
home care needs
ensure safe transitions of care
creating initial and on-going care plans utilizing nursing and home care assessments
attends IDT meetings and Core Team meetings as scheduled
Conducts history, physical exams and functional nursing assessments of enrolled participants
Develops and/or assists in the development of care plans for new and enrolled participants
provides nursing care and service to participants per plan of care and makes recommendations to IDT for services needed
Assists participants in maintaining optimum health
utilizes the standard of care tools
provides health education, and counseling to participants and caregivers facing chronic conditions and end of life issues
Triage any incoming phone calls from participant’s families or participants who call with questions or to report illness or concern
Makes appropriate referrals or treats within the scope of practice
Facilitates safe transitions of care ensuring medications are reconciled, home services are reinstated or requested, coordinates care with IDT members as appropriate
Engages in problem solving on a RN/clinical level
Communicates with families regarding delivery of services and changes in orders that will impact care
Completes documentation of all nursing care and services in medical record
Records all nursing encounters per PACE documentation standards
Completes assigned care plan assessments before the care plan (CP)
completes CP assessment documentation before or on the day of the CP
updates CP before the CP meeting
completes CP interventions and links a note before current CP is closed
reviews CP within 2 weeks after the CP meeting
Works with the Home Care Scheduler to coordinate and evaluate home services to maintain appropriate scheduling to meet the medical needs of the participant as evaluated using the Home Care Needs Assessment and IDT recommendations
Completes the Home Services Plan of Care for the CNA/HMK for the initial care plan and updates plan every 6 months or during a change of status
Assists Home Care Department on oversight/adherence to policy, competencies and training of CNA’s
Provides communication and problem solving to vendors with clinical/nursing issues
Conducts quarterly home health aide (CNA) observation visits of PACE employees providing personal care in the home
Provides ongoing direction and teaching to CNAs and evaluates their care and service delivery to ensure it meets PACE standards
Assists with orientation of new nursing staff and serves as a mentor to nursing students
Adheres to infectious disease and PPE standards of practice
Is knowledgeable and adheres to all nursing policies and procedures regarding standards of care
Can identify appropriate resources when unsure of specific policies or procedures
Attends staff meetings and in-services as required
Protects privacy and maintains confidentiality of sensitive participant, employee, and agency information
Performs related duties as assigned including covering the Day Center RN position PRN
Required to work weekends and holidays on a rotating basis as scheduled to deliver 24-hour care to enrolled participants