RN (Home Health)

Posted 5 months ago

The Registered Nurse in Home Health provides and directs provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations and agency policies. Also, The RN Registered Nurse job coordinates total plan of care with other health care professionals involved in care, and helps to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources. All done within a Point of Care setting. 

 Job Description: 

  • Provides clinical services within the scope of practice, as defined by the state laws governing the practice of nursing, in accordance with the plan of care, and in coordination with other members of the healthcare team. 
  • Makes the initial and/or comprehensive nursing evaluation visit, determines primary focus of care, develops the plan of care within State specific guidelines, and submits accurate, complete, and timely documentation, per policy. 
  • Regularly evaluates and re-evaluates (as warranted by changes in condition but at least every 60 days) the patient’s nursing needs. 
  • Performs patient comprehensive assessments at designated time points and develops the appropriate POC, in collaboration with physician orders. 
  • Ensures patients meet home health eligibility and medical necessity guidelines as defined by payer source. 
  • Initiates, develops, implements and makes necessary revisions to the plan of care in collaboration with the physician and other health care professionals involved in care. 
  • Makes referrals to other disciplines, as indicated by patient’s assessed need. 
  • Responds to outcome coordinator/coder and Patient Care Manager requests for clarification to OASIS assessments on the same day that the request for more information is sent. 
  • Plots patient encounters for the episode and determines needed RN encounters based on patient’s needs and regulations. 
  • Instructs and supervises the patient’s family/caregiver in the care of the patient and maintenance of a healthy environment for the patient. 
  • Actively participates in weekly case conferences. 
  • Maintains a current and accurate patient medication profile. 
  • After start of care (SOC) assessment, reports the status of the patient, assessed needs, and plan of care overview to the team leader on the same day (or by next business day if after hours). 
  • Observes, records and reports to the physician and/or team leader the patient’s signs and symptoms, response to treatment and changes in the patient’s condition, as appropriate. Ensures adequate Team Leader (TL) communication when physician follow-up is needed. 
  • Communicates changes in visit assignments, dates of scheduled visits, and schedule changes to scheduler and Patient Care Manager to ensure patient needs are met. 
  • Communicates timely and effectively with agency personnel and ordering physicians as required to process orders and OASIS data sets, schedule home visits, and deliver services to patients as ordered by physician and in accordance with applicable laws and regulation. 
  • Facilitates hand-off communication to RN and PCM who will cover patients in their absence, prior to scheduled days off. 
  • Performs regular and supervisory visits according to the plan of care and submits complete visit notes within 24 hours of completion visit. 
  • Directly and/or indirectly supervises care provided by the home health aides and licensed practical vocational nurses, provides instruction as appropriate, and assigns tasks according to State and federal regulations. 
  • Participates in on-call rotation. 
  • Adheres to and participates in the agency’s Episode Management process. 
  • Assists in the orientation of new agency personnel as assigned. 
  • Completes LHC required learning courses, additional assignments per DON request, as well as any state specific required
    training per state regulation/practice act requirements. 
  • Participates in the performance improvement plan and process to ensure positive patient outcomes. 


 License Requirements: 

  • Current RN licensure in the state of Maryland. 
  • Current CPR certification required. 
  • Current Driver’s License, vehicle insurance, and access to a dependable vehicle or public transportation. 


Candidates must have skilled home health experience with oasis assessments 


Job Features

Job CategoryAll Job Posts, Nursing

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