Job Purpose:
The Home Health Registered Nurse will work in the Home Care and Community Services team to assist individuals to live successfully and independently within the community. This role offers flexibility, independence, and autonomy for a motivated, self-starting nurse. This position will ensure that high quality supportive care, personal care and advanced personal cares are being provided as described in the clients plan of care and the high standards of MCFI Home Care. The Home Health Registered Nurse will conduct in-home health assessments, evaluation services, quality assurance visits and provide oversight of the delivery of services with passion and excellence. This position will be credentialed to work in all programs in the Home Care and Community Services Departments.

Essential Job Functions:
(Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.)

Department of Health Services Administrative Code reference: 105.17 (2) (b)
1. Evaluate the need for services and referrals to other services as appropriate.
2. Secure written orders from the clients physician. These orders are to be renewed once every 3 months unless the physician specifies that orders covering a period of time up to one year are appropriate, or when the clients needs change, whichever occurs first.
3. Develop a plan of care for the client giving full consideration to the clients preferences for service arrangements and choice of Caregivers. Interpret the plan to the Caregiver, include a copy of the plan in the clients health record, and review the plan at least every 60 days and update it as necessary.
Department of Health Services Administrative Code reference: DHS 105.17 (2) (b) 3m.
4. Promptly notify a clients physician or other appropriate medical personnel and legal representative of any significant changes observed or reported in the clients condition.

Department of Health Services Administrative Code reference: DHS 105.17 (2) (b)
5. Develop appropriate time and service reporting mechanisms for Caregivers and instruct the Caregiver on their use.
6. Give the Caregiver written instructions about the services to be performed and demonstrate to the Caregiver how to perform the services.
7. Evaluate the competency of the Caregiver to perform the services.
8. Demonstrate full compliance with state and federal personal care agency regulations, Agency policies/procedures and the Agency Code of Conduct.
9. Educate Caregivers in accordance with the direct care competency guidelines, in the provision of personal care, nurse delegated tasks, infection control, personal protective equipment, etc.
10. Maintain current knowledge of, and implement, best practices for personal care agencies.
Community Services
11. Responsible for the accurate and timely completing of documentation in various computer systems (Provider Connect, Synthesis, and other electronic health records as needed).
12. Identifies client specific outcomes/goals and provides ongoing monitoring of the effectiveness of the interventions.
13. Must be able to provide education to clients in the community and advocate for the needs of clients.

14. This position is majority community based and requires travel, using personal vehicle, into the community to conduct home visits in various residential settings.
15. While in the community, the person in this position regularly documents client home visit information on their laptop and must be able to use a cell phone to contact clients, staff, etc.
16. The person in this position frequently communicates with clients, medical personnel, legal representatives, personal care workers, etc. regarding the clients plan of care and must effectively communicate thoughts, ideas, and information both orally, in writing and in person with people from diverse backgrounds and abilities.