Registered Nurse

Commit to the Heritage culture. Be committed to providing excellent patient care while creating a culture of team work and compliance. Take ownership for your actions. Trust your home health team and always defend your team in a professional Be positive and offer constructive suggestions when appropriate.

Be proactive and take responsibility for your part in making our team run This includes responding to texts in a timely manner; communicating with home health Director, other disciplinary team members and office staff as well as physicians and medical director.

Recognize the continued ongoing focus areas compliance: Eligibility, Plan of Care, Aide Supervisory.

Always have good communication with team members, administrators, and f Go to Home health Director, compliance officer, human resource director or administrator with any concerns/compliance issues.

Understand the admission process (see blue home health binder and other printed tools for step by step documentation). Have admits and discharges in Consolo within 5

On day of admit/within 24 hours be compliant with the following steps:

1.  
   1. Write admission order
   2. Sign certification
   3. Arrange home health aide visits through aid supervisor
   4. Complete aide care plan
   5. Text home health administrative assistant of admission time, frequency of SN and Aide visits

Function within your scope of Know the rules or who to ask/where to find them. Refer to agency policy and procedures or home health state and federal guidelines for guidance.

Practice defensible Focus on why the patient needs home health now. Chart to the decline (why is this patient eligible for home health?) Use measurable data and provide enough information to support provider’s clinical judgement.

If a patient has been on home health for greater than 180 days, understand they are a compliance Work with team to determine continued eligibility.

Understand the importance of the “Notice of Election” This must be signed and turned in to the office on day of admit.

Understand who is eligible for Must have prognosis of less than 6 months to live if disease runs its normal course or more likely than not to die within 6 months as determined by Provider. The patient also must want our care and understand what home health provides.

Understand the best indicators for rapid decline are:

1.  
   1. Nutritional
   2. Functional
   3. Progressive deterioration in past 3 months
   4. Hospital visits/falls
   5. Serial lab tests

After patient admission to home health review the medication list with IDG team or provider ASAP to see which meds to continue and which will be covered by

After patient admission to home health text Home health Clinical director so he/she can

Offer and document “teaching and training” each patient visit. Make sure your patient understands our team approach in helping them meet their needs/goals. Actively listen to learn what those goals may be. Our goal is to provide “immediate relief”.

Have all notes in within 72 hours or 3 Be compliant with all notes in by end of the month for billing.

Make sure time and dates are correct- especially on death notes as they are difficult to change.

Understand Home health policies/procedures and code of conduct, where to find them and follow

Clean nursing bag once a month, weekly if possible, and follow appropriate bag technique as outlined in agency policy and

Update aide care plan as needed. For example, if you place a Foley catheter, change your aide care plan to include Foley catheter care. If Foley catheter is discontinued, also update aide care plan. New issues need a new care plan problem. Resolve when Always be updating aide care plan and communicating with your home health aide. For example, if the patient becomes unable to shower, change aide care plan.

Make sure to write order for new DME as needed and be aware of what DME belongs to patient what DME Medway provides. Clarify as such under DME notes.

Update the Aide Supervisor and home health administrative assistant if you need to change frequency of aide visits, so assignments always match orders, and write MD/NP

Update home health administrative assistant if changing nursing frequency and write physician

Update POA’s at least every two weeks and document (who, when, how long was conversation, what was discussed).

Update LSW/IDG team on declining/actively dying patients, or change in

Use LSW to assist when patient’s go to the doctor for any Home health has special billing codes.

When you enter a medication and a drug interaction pops up, acknowledge it before moving on. Notify provider so they are aware, then document your communication with provider in clinical or communication

When a patient is put on antibiotics, fill out an infection report and turn it in at the next IDG (No later than the end of the month to the Quality Director).

Document all falls under Fall Event in Consolo.

Conduct a medication reconciliation on each patient at least monthly, preferably prior to each This ensures the medication list sent to facilities matches Consolo so meds are filled correctly.

When picking up medication or having medications delivered, make sure Pharmacy knows when to bubble pack for facilities and remind pharmacy to send Narcotic sheets to

When doing a new admit, it is the case manager’s responsibility to call the patient's previous pharmacy and notify them that patient is on home health will be receiving medications through home health

After a death, follow the policy and procedure on destruction of medications at home or in facility. If family or facility refuses to destroy meds, document “family/facility refuses to destroy meds in presence of Home health RN at this ” This can be charted in the nursing summary or medication notes. Call home health pharmacy to notify them of death ASAP.

Documentation should be written as if a reviewer with no medical experience will read it in 1-5 years from Create a complete picture or story of the patient. Compose narratives that tie it all together. For example, tell what the patient’s life is like, what was their prior level of function compared to current abilities

Always document provider’s involvement with admission (phone call, length of conversation, what was discussed).

IDG’s are Attend each IDG where you have a patient unless you notify the home health clinical director of why you cannot attend. Attend monthly nursing meetings, and attend care conferences at facilities.

When visiting local facilities, you should be signing in/out and completing a summary of your visit as an outside agency. If you do not know where to find this documentation, please

Coverage for on call is a Being available to be on call one weekend per month and 3-4 weekdays during a month is expected.

If you are unable to make a regularly scheduled visit, it is up to you to attempt to find coverage using other team members and prn If you are unable to find coverage, notify the Home health Clinical Director to assist. Any uncovered visits that are missed need to have appropriate documentation in the form of a missed visit notification completed in the charting system.

Full and part time staff are expected to be available on dates surrounding company approved holidays unless approved time off has been obtained from your Director.

Scheduled time off can be requested by filling out a request for time off and leaving it in the Home health Clinical Director’s/ immediate supervisors box or

All employees are to maintain a current Human Resources file in order to remain an active employee. Reminders are provided by compliance and human resources It is expected that the required information and update be provided in an accurate and timely manner.

Be a positive force for Encourage, support and provide recognition for your team. Provide positive feedback and input at staff meetings.