The purpose of positions in this classification is to provide skilled nursing care to home care patients in accordance with the established plan of care. ESSENTIAL JOB DUTIES : Other duties may be required and assigned. Travels to patient homes and provides skilled nursing care within the established plan of care. Provides direct patient care including performance of tasks such as taking vitals, performing wound care, IV care, ostomy care, blood draws, injections, and the physical assessment of the overall patients medical condition. Reviews, sets-up, and administers medications as necessary per the established plan of care. Continually evaluates the patients condition and the effectiveness of treatments, plan of care, medications, and therapies. Conducts patient admissions and discharges as assigned. Ensures patients assessments and reassessments are completed in a timely and accurate manner. Works in collaboration with RN Case Manager and other patient care team members to assure coordination of care is provided to attain desired outcomes. Communicates with RN Case Managers and other members of the patients care team on the patients condition. Contacts and consults with the physician regarding the plan of care. Provides regular updates on the patients condition. Communicates significant changes in patient condition. Documents visit notes, treatments, and care. Records and reports symptoms and changes in patients condition. Verifies that physician orders are complete, accurate and cover the care and visits provided. Ensures orders are obtained prior to service delivery. Documents any verbal orders and follows up to secure written orders. Ensures required visits are completed in a timely manner. Follows-up with the Patient Care Managers to ensure notification and documentation of missed visits is provided in accordance with proper procedures in a timely manner. Documents patient refusal of visits or care. Initiates and documents timely discharges. Provides information, instruction and education to the patient, patient family members and caregivers in proper care. Verifies that instructions are being followed and carried-out. Responds to calls from patients, family members and others and provides appropriate follow-up to address needs, issues, or concerns. Assists in assigning and monitoring the work of Home Health Aides and Licensed Practical Nurses. Monitors and reviews the provision of care provided by the HHAs and LPNs and communicates concerns to the RN Case Manager and Patient Care Manager. Provides instruction and training as necessary. Completes and submits timesheets or time logs to supervisor on a timely basis which accurately document hours, mileage, travel and other reimbursable and non-reimbursable time worked. Attends safety training sessions and ensures for compliance with safety rules and procedures. Identifies and notifies the Patient Care Manager and Safety Committee of potential safety hazards. Reports any work-related accidents and injuries in a timely manner. Complies with the procedures for documenting and submitting leave and light duty time. Attends and participates in mandatory meetings, in-services, and conferences. Assists with audits as requested. Conducts Home Connections as assigned for HHU Xtra Care. Travels to patient homes and conducts a health coaching visit following a patients discharge. MARGINAL JOB DUTIES Sets up and monitors HomMed monitors.