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Missouri, United States
Onsite
Organizes, coordinates and directs the ongoing provision of the services to the patients assigned to them within the agency. Ensures the delivery of quality patient care and when appropriate, provides supervision during all service hours including, but not limited to supervision of LPN's and CNA's as required. Initiates and maintains communication with the patients, families, physicians, other home health/hospice team members and agencies as needed to promote positive patient outcomes and appropriate use of healthcare resources. Performs the initial and follow-up comprehensive assessments, drug regimen reviews and reconciliation. Works with the patient, family, physician, other home health/hospice team members to develop and update the plan of care. Documents into the EMR at point of care to ensure up-to-date patient records so that problems, plans, actions and goals are accurately and clearly stated, and changes are reflected as they occur. Completes required physician summaries at SOC, Recert, Transfer, ROC and discharge. Documents any communication with the home health/hospice team. Maintains an accurate visit schedule to reflect projected and actual patient visits. Participates in the agency's Nurse on-call schedule, weekly case conference meetings, and the Quality Assurance and Performance Improvement (QAPI) Program. Demonstrate familiarity with policies of the agency and rules and regulatory agencies, which aid in determining policies. May be assigned other duties as appropriate.
