OASIS Registered Nurse (RN, Visiting Nurse) - HomeCare

About the role

Provides skilled nursing care to clients in their homes or community health settings ensuring the delivery of outcome based, high quality, cost effective care.

Responsibilities

• Reviews referrals, and initiates contact with client and family.
• Conducts a complete nursing assessment based on referral data, client/family interview, and clinical observation of patient health status.
• Develops a plan of care in collaboration with client and all disciplines based on assessment data which documents need for services, appropriate discharge planning, short- and long-term goals, and utilization of appropriate resources.
• Completes OASIS time point assessments throughout a patient’s episode which provides objectivity and consistency.
• Makes follow-up visits to provide skilled care to assess disease progress and evaluates response to treatment; provides support to client/family utilizing teaching principles to promote and restore health and prevent disease and disability; coordinates care with providers.
• Teaches patients and reinforces client/caregiver teaching and education.
• Refers, collaborates, and coordinates all client care services.
• Consults with physician regarding client needs and plan of care.
• Directs LPNs in carrying out the established plan of care.
• Directs Home Care Aides and supervises plan of care.
• Refers client/family to other community resources as needed.
• Attends and participates in in-service education program.
• Sets up and maintains a client record utilizing the Agency’s standard for documentation.
• Sets up and maintains a client record utilizing the Agency’s standard for documentation.
• Participates in client care conferences, staff, and group meetings, IDT, and LEAN Process Management.
• Participates in daily SBAR report with nurse care coordinator.
• Completes reporting requirements on a timely basis.
• Assumes the role of team leader on a rotating basis.
• Performs other duties as assigned.

Qualifications

• Education: Graduate of an Associate’s Degree or diploma program in nursing required. Graduate of NLN approved BSN program preferred.
• Experience: One year nursing experience or one year nursing experience in a specialty required. Medical/surgery or home care experience preferred.
• Licensure: Registered nurse with a license to practice in the state of CT required.
• Knowledge, skills, and ability requirements: Computer skills.