1.Implement nursing portion of care plan in coordination with other team members based on physician’s orders.
A.Obtain permission for delivery of care.Verifies consents and authorizations in clinical record.
B.Performs physical, psychosocial, and spiritual assessment on all hospice patients.
C. Develops a written/computerized plan of care for each patient.
D. Provides skilled nursing care.
E. Responds to the physical, mental, social, and emotional needs of terminally ill patients and their families.Offers ongoing support and palliative care.
F. Reassesses patient’s condition and plan of care and re-evaluates and updates as necessary.
G.Obtains needed supplies and equipment to provide care.
H.Review and instruct regarding purpose, dosage, route, frequency and side effects of medication with patient and family.
I.Follows up with obtaining lab results and notifying physician of any significant results.
J.Initiates needed referrals to other disciplines and/or community resources.
K.Show respect for the dignity of the individual patient/family/caregiver.
L.Provide care for 5 or more patients daily.
M.Maintain a caseload of 13 to 15 patients.
2.Assesses patient for pain and symptom management and treats appropriately.
A.Collaborates with Primary MD (or HCN physician only if attending is unavailable) to develop a pain and symptom management plan to maintain optimal patient comfort.
B.Demonstrates and documents ongoing reassessments in collaboration with attending physician or HCN physician if attending is unavailable.
C.Demonstrates knowledge of medications and correct administration of same.
D. Demonstrates knowledge of non-pharmacological pain and symptom management.
E. Accurately provides and documents education of patient/family regarding both pharmacologic and non-pharmacologic pain and symptom management, which ensures maximum effectiveness, compliance and safety.
F. Provides written educational materials in reference to pain and symptom management to patient/family.
3.Actively participates in Interdisciplinary Team (IDT) meetings to collaborate with team in evaluating and modifying individualized plans of care which are patient driven and identify patient/family goals.
A. Collaborates with IDT during team meeting by providing succinct, accurate patient/family information needed for appropriate goal setting.
B.Maintains timely, thorough patient record of comprehensive assessment and ongoing modification of Plans/Interventions/Outcomes (PIOs).
4.Participate and collaborate with Team Manager in delivery of care and meeting organization’s goals.
A.Communicates patient information verbally and by maintaining up to date paperwork/computer data.
B.Seeks guidance for problem areas.
5.Obtain all necessary physicians orders and collaborates with physician as patient’s needs dictate.
A. Attempts to contact primary physician.
B.Obtains orders from Hospice Medical Director when appropriate.Follows up with Primary Physician and documents contact.Orders are sent weekly and signed within 30 days.
C.Orders are written for changes in medications, supplemental orders are updated and signed, and visit frequency.
A. Teach, supervise and counsel patient/family/caregiver regarding physical care and other problems related to the patient’s terminal condition, including death procedure.
B.Explains procedures and interventions.
C. Establishes patient education goals and assesses effectiveness of teaching by feedback and /or return demonstration by patient/family/caregiver.
D.Utilizes resources and teaches techniques consistent with patient’s ability and comprehension.
E.Demonstrates understanding and respect for cultural practices.
F.Promotes an attitude conducive to learning, independence and self-care.
7.Supervise Home Health Aides (HHA).
A.Establishes comprehensive plan of care for HHA to reflect physician’s orders.
B. Supervises HHA at least every two weeks.
C.Updates HHA plan of care as per HCN policy.
8.Accurately document all care in an appropriate and timely manner on computer and written forms in accordance with HCN policies and procedures as well as state and federal regulations and JCAHO standards.
A.Clinical notes and/or progress notes.
B.Interdisciplinary plan of care.
C.HHA plan of care, supervision, and orientation.
D.Submits documentation within agency guidelines.
E. Documentation is accurate, complete and legible.
F.Chart review scores 85% or more.
9.Guide, direct, supervise Licensed Practical Nurse (LPN) in delivery of care.
A. Provides verbal, written and computerized information.
B.Directs delivery of care and time management.
10.Support and implement Hospice policies regarding patient/family care.
A. Explains HCN policies and applies to individual patient needs.
11.Participate in 2ndon call rotation, and 1ston call as needed.
A. Maintains communication by being accessible via beeper/phone/cell phone.
C.Visits patients as needed.
12.Notifies Team Manager of patients who need to be seen on weekends or holidays and submits updated information to the on-call nurse.
A. Provides accurate information.
B.Provides information in a timely manner.
13.Functions as an integral part of the Interdisciplinary Team by expanding theoretical knowledge base, improving clinical techniques and enhancing interpersonal relations.
A.Demonstrates current and in-depth knowledge of clinical practice and available community resources.
B.Utilizes sound nursing judgment when carrying out patient’s treatment plan in accordance with standards of nursing practice.
C.Establishes and maintains effective working relationship with interdisciplinary team and office staff.
D.Seeks out information and knowledge to enhance level of expertise.
E. Shares information and knowledge learned with peers.
14. Performs job functions in a fiscally responsible manner consistent with agency’s mission and vision.
A.Utilizes sound time management skills in planning day-to-day activities and fulfilling job responsibilities.
B.Demonstrates appropriate and efficient use of supplies and equipment.
C.Consistently meets the productivity standard established by the agency.
15. Demonstrates and promotes respect for patient’s rights.
A.Demonstrates awareness of and compliance with the Patients Bill of Rights and the Patient Self Determination Act.
B.Maintains patient confidentiality.
C.Assists in making reasonable accommodations for special groups, i.e., hearing, visually, physically and mentally impaired.
16. Incorporate HCN’s commitment to customer service and continuous quality improvement into daily work habits.
A.Courteous and considerate in person and on the telephone
B.Promotes positive co-worker relationships, teamwork and cooperation, both within the department and across the departmental lines.
C. Participates in performance improvement data collection and Continuous Quality Improvement projects, as assigned, and takes individual responsibility.
17.Adheres to general policies and procedures of the organization/department including:
A.Corporate Compliance, Code of Ethical Conduct.
B.Emergency /disaster preparedness protocols.
C.Fire/Safety prevention protocols.
D.Departmental in-service education program requirements.
E.Policies and procedures (attendance, punctuality, appearance, professional attitude, etc.)
F.Quality improvement activities.
G.Job related self-development education activities.
H.Infection control practices and procedures.
I.Joint Commission and other regulatory requirements.
- Graduate from an accredited School of Nursing. Bachelor's Degree in Nursing, preferred.
- Licensed to practice as a Registered Professional Nurse in New York State.
- Minimum of two (2) years of hands-on experience as a RN, including medical/surgical, required. Home Care, Hospice, or Oncology, preferred.
- Current and Valid Driver's License, required.