Licensed Practical Nurse (Day, Evening, & Night Shift) Full-time/ Part-time/ PRN -Briscoe

About the role

The Licensed Practical Nurse works with agency clients in the Adult Residential Program (both STC and LTH/IOP). The Licensed Practical Nurse orients clients to the agency and the expectations of services which are to be received through the Medical Staff and manages the agency clients’ medical care.

Responsibilities

• Assess potential residents for appropriateness for the treatment program;
• Complete an updated assessment on each client after admissions;
• Complete a medical treatment/discharge plan based on updated assessment;
• Communicate the treatment plan with the treatment team upon admission and on a monthly basis;
• Provide on-going health education to all residents as outlined in the Residential Program Manual;
• Provide on-going assessment of acute medical/nursing needs of all residents and refers residents to appropriate treatment centers;
• Maintain HIPAA guidelines;
• Perform other duties as assigned.

Client Induction

• Nurse will review all admissions packets to determine if potential client is eligible for program and if they need PPD, medical records requested, H & P, Psych evaluation.
• At time of admission, ALL new admits will meet with a staff nurse. At that time, MARs form, determination of med call schedule for patient, education on med refill process, med slips, and general health conduct will be explained and documented by the nurse and placed into a medical chart.
• Nurse will place PPD within 72 hours of admission to the program and read within 72 hours of placement. Any clients with a positive PPD or showing signs of possible TB infection will be referred to the Wetmore Clinic for further follow up.
• Photocopy any insurance or Medicaid card for chart. Document emergency contact and relationship in the event client goes to ER or needs financial assistance for medical.
• Review of chart will be determine if patient will go onto the psychiatry schedule based on initial determination to enter program. (i.e. follow-up, first visit within 30 days, or prn).

Psychiatry

• Work with Community Health Center (CHC) staff to ensure that clients who are in need of a psych evaluation as indicated by their initial screen or at the Chief Medical Officer’s request are scheduled for an appointment.
• Work with treatment staff to report appointments and assist in scheduling if needed.
• Print out notes/visits from the EHR for client charts and submit for filing.
• Receive any verbal orders by providers, document, and facilitate them.

Medical

• Pick up medical slips from the treatment team office twice daily.
• Take vital signs on patients that have medical complaints that require triage and present them to the CHC with that patient’s chart ready for review.
• All HIV screening will be offered to OHL clients by the CHC. The Nurse will coordinate with the CHC as needed.
• Call and coordinate clients to CHC as needed.
• Review all charts seen by the CHC and or arrive by medical feedback sheet and follow instructions as directed. It may be necessary to educate client on diagnosis and treatment plan with goals.
• Print out notes/visits from electronic health records for client charts and submit them for filing.

Treatment Team Meetings

• Attend the weekly treatment team meeting and bring any concerns to the Counselors regarding clients and listen to concerns of the Counselors and assist if it is a Medical Staff issue.
• Bring and present the MAR book in the weekly treatment team meetings.

Discharge

• Obtain clients' personal medication from the front desk and sign an acknowledgement receipt of the medications that they receive. This receipt is to be scanned into the client's chart.
• Report with night staff for shift change.
• Check in with the Front Desk to know if any clients went to the ER after hours and attain paperwork. Medical visits must be accompanied with a medical feedback sheet, any pertinent labs, and notes for the visit. All clients going out of the house for medical appointments will be obligated to stop at the nurse's office to report what occurred in the visit and submit any paperwork before going back on the floor.
• Facilitate medication refills by instructing clients how to fill out a medication refill request, attain refills, and arrange for payment.
• Call medications in to pharmacy prior to departure, patient must fill out sheet with financial request.
• Document on a pharmacy log which clients have pending medications.
• On arrival of medications, document all arrivals into each client's chart.
• Insert any medication information sheets into patient's chart.
• Any clients that have stat prescriptions send and fill ASAP if they are antibiotics, anti-inflammatory medication, etc…
• Clients who do not request medications prior to running out will have this reported to the client's individual Counselor.

Protocol

• New admits will have a medical record in the EHR. These records will hold clients' recent PPD, intake packet from admissions, a medical reconciliation form of all meds, and any medical records that arrived for the client such as History and Physical, Psych Evaluations, Hospital Records, Labs. This chart will be made when the nurse meets the client and is assembled by the Medical Staff.
• The Medical Staff will establish appropriate medications which can be used at OHL. Narcotics may not be used in the Adult Residential Program (there may be exceptions in a very few cases to this policy but approval for the use of any narcotic must come from the Program Manager prior to administration of such medication.) Certain pain relievers are acceptable on a case by case basis with documentation from the medical provider who provided the pain reliever. The Nurse may be instructed to give clients comfort medications as outlined in the policy and instructed by Community Health Center Staff or the Chief Medical Officer.
• The Medical Staff will establish what medication calls the client will use for their medication regiment. There are four medication calls per day. As needed medications will be used on a case by case basis. This schedule will be written down for the client to have as a reference and present to their Counselor.
• The clients' schedule will be documented into a log for medication calls. This log will allow nursing staff to know when a client has been missing medication calls or not taking them correctly.
• Misplaced medication calls will results in client missing medication if it is too close to the next medication call based on clinical judgment. There will only be three grace opportunities to take late or missed medications. At that time the nurse will notify that client's Counselor of the behavior to have it addressed as part of their treatment. These cases should be logged into nurse's log to be presented in treatment team meetings.

Discharge Planning

• All clients are to be told their obligation to stop by the Nursing Office prior to discharge or graduation to receive their medications. Clients are to be made aware that if they leave OHL at night or on a weekend, they may return to the nurses' office in 72 hours, medications will be discarded and a note in chart will indicate last day at OHL noting they did not participate in a discharge plan as contracted.
• All new clients will sign in their medications and sign out their medications. All clients will be given the phone numbers to Behavioral Health and the Primary Care Clinic's as part of their orientation in the event they leave without a discharge plan.

Daily Task List

• Report in with staff. Review the night log for any ER visits or medical complaints from the night. Match to Incident Reports as needed.
• Review all needed actions for the day dealing with the CHC as needed: medication orders, lab draws, chart reviews of or any pending documents to file.
• Review the intake schedule for admissions and prepare appropriately.
• Review medical slips submitted by clients of OHL. Triage slips to determine urgency of CHC visit. Number of clients seen is variable. Report client needs to the CHC if warranted.
• Respond to emails in timely fashion and carbon copy appropriate parties.
• Cook up new admits into the CHC for an initial H&P and placement of PPD. Range of clients is determined on activity of admissions.
• Conduct medication calls.
• Review Admissions packets on all candidates for the Residential Program and advise on eligibility.