Provides age-appropriate skilled nursing care to patients in their place of residence in accordance with agency policy and procedure and state and federal regulations. Teaches the patient/family disease process and self-care needs. Monitors physiological state to determine an appropriate level of safety and comfort. Provides services requiring nursing skills in accordance with the plan of care. Develops and coordinates the plan of care and provides case management. Performs duties consistent with the nursing practice act that includes the standards of competent performance including Title 16, Chapter 14, Section 144.3 of the California Code of Regulations.
- Provides the initial all system nursing assessment prior to the provision of care.
- Initiates the plan of care and necessary revisions including obtaining written physician orders for changes.
- Provides care and services in accordance with the plan of care.
- Performs assessment/data collection in an on-going systematic manner, focusing on physiologic, psychosocial, cultural, spiritual and cognitive status; also nutrition, pain, patient/family education, family involvement and patient advocacy.
- Provides ongoing periodic all system assessment of the patient and the patient-s equipment needs.
- Initiates preventative and rehabilitative nursing procedure (Home Health).
- Initiates timely discharges based on goals.
- Educates and instructs the patient, patient-s family or other staff as required.
- Counsels the patient and family in meeting nursing and related needs.
- Supervises and teaches LVN-s and HHA-s as required for patient care.
- Provides nursing care through all phases of care taking into consideration age and developmental needs.
- Documentation and Communication: Documents all care, interventions and care coordination per law, regulation and agency policy.
- Notifies the patient-s attending MD, Podiatrist and other professional persons and responsible staff of significant changes in the patient-s condition in a timely manner.
- Assists in coordinating all services provided.
- Consults with other health professionals when needed.
- Planning, Organizing and Productivity: Effectively plans and organizes work assignment, manages and sets competitive priorities, and completes work assignments with a minimum of direct supervision per agency policy and within established time frames.
- Adheres to the services policy and principles of the Kaiser Permanente Medical Care Program.
- Supervises Home Health aides and LVNs according to law, regulation and agency policy.
- Professional Behavior: Behaves in a courteous professional manner with patients, health professionals and maintain patient confidentiality.
- Acts as a patient advocate in utilizing Medicare, MediCal, Health Plan and community resources.
- Participates in Departmental Quality Assurance activities and Utilization Review activities as requested.
- Self-Development: Selects and attends education programs to keep current in area of practice.
- Utilizes new knowledge and skills.
- Participates in in-service programs.
- Annually prepares realistic professional goals and reviews their progress with Supervisor.
- Perform other related duties as necessary.
- Two (2) years of applicable registered nurse experience within the last five (5) years, as determined by the Employer, of which at least six (6) months must be home health experience within a hospital-based or community based home health agency.
- Graduate from an approved school of professional nursing (AA, Diploma, or BSN).
License, Certification, Registration
- Current license to practice as a Registered Nurse in California.
- BLS required.
- Valid driver-s license.
- Knowledge of the nursing process.
- Commitment to Service Orientation.
- Effective written and oral communication skills (in English).
- Good interpersonal skills.
- Also refer to Position Specifications outlined in the appropriate collective bargaining agreement.
WOUND / OSTOMY - Three (3) months experience as a WOCN required. One (1) year of experience as a WOCN preferred. WOCN or CERTN certification required. Graduate from an accredited WOCN education program.
PALLIATIVE CARE - Two (2) years of recent (within the last five (5) years) experience in case management, and recent experience in palliative care (such as oncology, home health, hospice, etc.) to include experience in initiating and participating in end of life discussions with patients and families, facilitating family conferences and advanced care planning.
- Oncology, hospice or care of terminally ill experience preferred if working within the Hospice Department.
- Experience in automated clinical information systems preferred.
- Computer literate preferred.
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