Description: Job Summary:
Provides age-appropriate skilled nursing care to patients in their place of residence in accordance with agency policy and procedure and state and federal regulations. Teaches the patient/family disease process and self-care needs. Monitors physiological state to determine an appropriate level of safety and comfort. Provides services requiring nursing skills in accordance with the plan of care. Develops and coordinates the plan of care and provides case management. Performs duties consistent with the nursing practice act that includes the standards of competent performance including Title 16, Chapter 14, Section 144.3 of the California Code of Regulations.
Essential Responsibilities:

Provision of Care
Provides the initial all system nursing assessment prior to the provision of care.
Initiates the plan of care and necessary revisions including obtaining written physician orders for changes.
Provides care and services in accordance with the plan of care.
Performs assessment/data collection in an on-going systematic manner, focusing on physiologic, psychosocial, cultural, spiritual and cognitive status; also nutrition, pain, patient/family education, family involvement and patient advocacy.
Provides ongoing periodic all system assessment of the patient and the patient’s equipment needs.
Initiates preventative and rehabilitative nursing procedure (Home Health).
Initiates timely discharges based on goals.
Educates and instructs the patient, patient’s family or other staff as required.
Counsels the patient and family in meeting nursing and related needs.
Supervises and teaches LVN’s and HHA’s as required for patient care.
Provides nursing care through all phases of care taking into consideration age and developmental needs.
Documentation and Communication
Documents all care, interventions and care coordination per law, regulation and agency policy.
Notifies the patient’s attending MD, Podiatrist and other professional persons and responsible staff of significant changes in the patient’s condition in a timely manner.
Assists in coordinating all services provided.
Consults with other health professionals when needed.
Planning, Organizing and Productivity
Effectively plans and organizes work assignment, manages and sets competitive priorities, and completes work assignments with a minimum of direct supervision per agency policy and within established time frames.
Adheres to the services policy and principles of the Kaiser Permanente Medical Care Program.
Supervises Home Health aides and LVNs according to law, regulation and agency policy.
Professional Behavior
Behaves in a courteous professional manner with patients, health professionals and maintain patient confidentiality.
Acts as a patient advocate in utilizing Medicare, MediCal, Health Plan and community resources.
Participates in Departmental Quality Assurance activities and Utilization Review activities as requested.
Self-Development
Selects and attends education programs to keep current in area of practice.
Utilizes new knowledge and skills.
Participates in in-service programs.
Annually prepares realistic professional goals and reviews their progress with Supervisor.
Perform other related duties as necessary.
Supervisory Responsibilities:
The job has no supervisory responsibilities.
Basic Qualifications: Experience

Minimum two (2) years applicable registered nurse experience within the last five (5) years, as determined by the Employer, of which at least six (6) months must be home health experience within a hospital-based or community based home health agency.

WOUND/OSTOMY: Three (3) months experience as a WOCN required.
PALLIATIVE CARE: Two (2) years of recent experience(within the last five (5) years) in case management, and recent experience in palliative care (such as oncology, home health, hospice, etc.) to include experience in initiating and participating in end of life discussions with patients and families, facilitating family conferences and advanced care planning. Education
High School Diploma/GED.Graduate from an approved school of professional nursing (AA, Diploma, or BSN)
Graduate from an accredited WOCN education program. License, Certification, Registration Wound Care Nurse Certificate OR Wound Ostomy Care Nurse Certificate Driver's License (California)
Registered Nurse License (California)
Basic Life Support
Additional Requirements:
Knowledge of the nursing processCommitment to Service OrientationEffective written and oral communication skills (in English)Good interpersonal skillsAlso refer to Position Specifications outlined in the appropriate collective bargaining agreement.
SPECIALTY AREA: If no qualified candidate, will be willing to train. Where indicated, candidates in training are required to obtain appropriate certification (s) within the designated time frame for a particular field of practice. Preferred Qualifications:
Computer literate preferredExperience in automated clinical information systems preferred.Oncology, hospice or care of terminally ill experience preferred if working within the Hospice Department.
One ( 1) year of experience as a WOCN preferred.