Job Summary   Establish and utilize the plan of care to implement and direct patient care (the plan of care is updated at least monthly and also as changes occur); progress notes should reflect utilization of the care plan Recognize the patient and family as the unit of care Inform the patient's insurance case manager via the Managed Care Liaison about the ordered visit frequency plan(s) for patient care and patient's status Provide clinical supervision of the hospice home care team Home Health Aide (HHA) care plans must be reviewed and/or updated with each onsite visit and initialed; the original is kept on the chart and staff are responsible for weekly updates Perform HHA onsite supervisory visits every 14 days according to Medicare guidelines, and conduct an onsite with the HHA during the first week after start of care Performs all aspects of the skilled nurse home visit: Plan and prepare for the visit Perform skilled interventions including teaching, pain management, and symptom control Report changes in patient condition or other pertinent data to physician as needed Comply with established SN frequency as per form 485; change frequency as needed according to physician orders Document assessment of patient's status and response to skilled intervention and teaching on hospice SN progress note Document ongoing discharge planning from start of care, and prepare discharge summary according to agency policy Ensure that documentation shows subsequent planned visits with patient Report unexpected changes in patient condition or other pertinent data to the physician according to agency policy Provide appropriate support at the time of death and during the period of bereavement Utilize supply requisition process in an appropriate and cost effective manner Inform the Managed Care Liaison of patient updates regarding care, status, and frequency of visits for all disciplines Teach the patient/family about care needs, disease process, and health maintenance measures Ensure documentation on the hospice SN progress notes reflect patient/caregiver response to skilled instruction or treatment, as well as an update of status/problems Provide skilled instructions according to the nursing plan of care and any teaching guides (as applicable) Teach and counsel patient, family, or other primary caregiver regarding expected disease progression, care techniques, and other health measures Ensure that the patient’s medical record reflects that the patient and caregiver are included in the planning and rendering of care as evidenced by patient/family response to plan of care/intervention/instructions Remain knowledgeable regarding current hospice trends and insurance issues Participate in joint visits with the Hospice PCC, PRN, and/or designee at least annually Seek attending physician, hospice medical director, or hospice PCC intervention and follow up appropriately Maintain current update of clinical skills and recognize/report skills review needs to the Hospice PCC Demonstrate courtesy, compassion, tact, patience, and respect for patients, families, and co-workers Practice hospice nursing with utilization of appropriate palliative tools (i.e. open communication, empathy, acceptance of spiritual and cultural differences, ability to assess and manage caregiver needs/problems, accurate pain assessment and treatment, teaching the family the normal processes of the human body as death approaches, and understanding of stages of grief and bereavement) Recognize and assume patient/family advocacy role Call the Team Assistant's voice mail each morning with daily plans and changes Document all patient care in reimbursable and professional terminology as evidenced by audit review The Nursing Plan of Care and any teaching guides used must be on the patient's clinical record within the first week from start of care The Plan of care is to be utilized with planning SN visits and updated accordingly Medication profiles will have classification completed and on the patient's medical record within the first week of start of care; medication profiles must be updated once per month and/or with additions or changes and signed/dated Discharge summaries are due within 48 hours after the patient is discharged from service and are to be submitted to the Hospice PCC Admission paperwork and orders must be completed within 48 hours and are to be submitted to the PCC Recertification’s are due three (3) weeks prior to the end of the current certification period, and must be submitted to the PCC for review Phone orders are to be submitted for processing within 48 hours after receiving the order QCC reports are to be completed by the involved staff person within 24 hours and are to be submitted to the PCC Weekly schedules are to be submitted to the Hospice PCC and Team Assistant on Thursday for the coming week Payroll sheets with SN progress notes are to be submitted every Monday, Wednesday, and Friday by 8:00 AM; exceptions for holidays will be determined Nursing staff will perform billing audits and chart audits monthly as directed by the PCC

Education and Experience

Minimum Education: Successful completion of an accredited Registered Nursing Program

Preferred Education: Bachelor of Science in Nursing (BSN)

Experience: One (1) or more years’ prior med-surg experience is required

Certificates, Licenses, Registrations

Applicant must be licensed to work as a Registered Nurse in the Commonwealth of Virginia and must hold a current BLS certification. CHPN certification is preferred