REGISTERED NURSE (full-time)

About the Role

Oversees all medical aspects of the health of individuals supported by the agency, ensuring their physical well-being and advocating for their healthcare needs.

Responsibilities

• Conduct at least one face-to-face contact weekly with each person supported to ensure physical well-being.
• Schedule required medical appointments based on individual needs and regulatory requirements.
• Complete all nursing assessments as required.
• Ensure an adequate supply of medication for each person supported by checking medication storage at least once per month.
• Ensure persons supported receive prescribed medications, treatments, and diets as ordered.
• Review all routine, pre- and post-surgical, and Urgent Care/ER visit summaries in their entirety; document findings, assessments, and recommendations in nursing notes as applicable.
• Serve as an advocate for the person supported during medical care with the prescriber.
• Maintain a high level of professionalism, lead professional settings such as audits, and represent the agency in conferences.
• Visit persons supported during hospitalizations or nursing rehab admissions at least once a week or as needed based on medical necessity and acuity.
• Provide RN coverage for other Intellectual/Developmental Disability (I/DD) sites as necessary.

Clinical Responsibilities

• Actively participate as a member of the person supported program planning team.
• Ensure all health and medical-related issues are discussed with the team to foster awareness and develop a plan of care.
• Participate in program planning and goal development related to the person supported's health and medical needs.

Record Keeping Responsibilities

• Maintain all mandated medical records, including:
  • Nursing notes (minimum of once a month)
  • Medical visit summaries
  • Discharge summaries from Urgent Care/ER/Hospitalizations
  • Prescriber's orders/scripts
  • Plans of Nursing Services (PONS)
• Complete all medical reports for the person supported (CFA, ICFs, ISP, IRA) in a timely manner.
• Participate in meetings to provide medical updates to the team and circle of supports.
• Oversee person supported charts, including:
  • MAR/Treatment Records (minimum of once a week)
  • Updated Prescriptions/Formulary
  • BM Charts (minimum of once a week)
  • Medical Books
  • Flowsheets (e.g., Vital signs, Blood Sugar Records, Body Check, Head Injury, Seizure, Repositioning, Controlled Substance Count)
  • PONS (updated annually or when there is a change in diagnosis or treatment plan)
• Participate in the internal auditing process using the Chart Audit Tool on a quarterly basis.

Staff Training Responsibilities

• Provide in-service training to staff during scheduled trainings, staff meetings, and shift meetings on:
  • General health issues (e.g., Illness Detection, OSHA/Infection Control, First Aid, Diets, Diabetes, Seizures, Epi-Pen, AMAP, Hygiene Issues)
  • Person-specific needs, including procedures/issues, purpose of treatment, precautions, and possible side effects
• Conduct PONS training annually or when there is a change in diagnosis or treatment plan.
• Train AMAP staff on responsibilities regarding medication administration.

Oversight Responsibilities

• Ensure health and safety procedures are followed according to State and Federal regulations.
• Triage health concerns of individuals via telephone and provide directives to staff as necessary.
• Direct staff to utilize Telehealth services when necessary to decrease Urgent Care/ER visits.
• Supervise AMAPs in dispensing medication and treatments as per prescriber's orders.
• Ensure medication errors are reported and train AMAPs on preventing future errors.

Performance Expectations

• Maintain a high standard of work quality and productivity.
• Possess comprehensive knowledge of the person supported, including program plans, medical status, and day program.
• Follow through on issues in a timely manner.
• Demonstrate good judgment and decision-making.
• Serve as a positive role model for both staff and persons supported.
• Maintain a good attitude, team spirit, flexibility, and initiative.
• Ensure good attendance and responsiveness to directives from the Nursing Supervisor.

Requirements

• Licensed Registered Nurse (RN).
• One year of experience working with individuals with an intellectual/developmental disability preferred.
• Respect for the person supported and commitment to person-first language and the Justice Center's Code of Conduct.
• Valid New York State Driver's License.