DUTIES * To provide nursing care, in accordance with the client's service plan to include comprehensive evaluation, monitoring of the client’s condition, health promotion and prevention coordination of services, teaching and training activities, and direct nursing care RESPONSIBILITIES * Coordinate total client services by conducting comprehensive evaluation, monitoring the client's condition, promoting sound preventive practices, coordinating services, and teaching and training activities * Evaluate the effectiveness of nursing service to the client and family, on an ongoing basis * Perform admission, transfer, re-certification, resumption of care, and discharge paperwork for the home care client and updates Service Plan per policy * Prepare and present client’s record to the Clinical Record Review Committee, as indicated * Consult with the attending physician concerning alterations of Client Service plans, check with the appropriate supervisor and make changes, as appropriate * Coordinate client services. Supervises all services provided for the medically weakened clients * Submit clinical notes, no less often than weekly, and progress notes, and other clinical record forms, outlining the services rendered, as indicated * Submit a tally of client care visits made each day * Participate in case conferences, discuss, with the supervisor, problems concerning the clients and how they may best be handled * Discuss, with the appropriate supervisor, the need for the involvement of other members of the health team such as the Personal care assistant, LPN, Companion, and Sitter. * Obtain orders for paraprofessional service and submit a referral to the appropriate personnel * Participate in the client’s discharge planning process * Cooperate with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive service plan * Participate in staff development meeting * Continually strive to improve his/her nursing care skills by attending in-service education, through formal education, attendance at workshops, conferences, active participation in professional and related organizations, and individual research and reading * Participate in the development, and periodic revision, of the physician's service plan and process change orders, as needed * Maintain an on-going knowledge of current drug therapy * Adhere to federal, state, and accreditation requirements * May be requested, by Nursing Coordinator, to fill in for the other nurses COORDINATES THE ADMISSION OF A CLIENT TO THE AGENCY * Conduct an initial, and ongoing, comprehensive assessment of the client’s needs, at appropriate time frames * Conduct a physical examination of the client, including vital signs, physical assessment, mental status, appetite, and type of diet, etc. * Evaluate the client, family member(s), and home situation to determine what health teaching will be required * Evaluate the client's environment to determine what assistance will be available from family members, in caring for the client * Evaluate the client's condition, and home situation, to determine if the services of a Personal care assistant, companion or sitter will be required and the frequency of this service * Explain nursing, and other Agency, services to clients and families, as a part of planning for care * Develop, and implement, the nursing service plan * May be assigned by supervisor to assess/supervise LPN, PCA, Companion or Sitter caregivers by direct observation or demonstration of the tasks they are assigned to perform PROVIDES SKILLED NURSING CARE AS OUTLINED IN THE NURSING SERVICE PLAN * Nursing services, treatments, and preventative procedures requiring substantial specialized skill and ordered, by the physician * The initiation of preventative and rehabilitative nursing procedures, as appropriate for the client's care and safety * Observing signs, symptoms, and reporting, to the physician, reactions to treatments, including drugs, as well as changes in the client's physical or emotional condition * Teaching, supervising, and counseling the client, and caregivers, regarding the nursing care needs and other related problems of the client at home * Provide guidance, and supervision, to the LPN and supervises the LPN, per Agency policy * Participate in the educational experiences for student nurses * Participate in the planning, operation, and evaluation of the nursing service ASSUMES RESPONSIBILITY FOR THE CARE GIVEN BY THE PARAPROFESSIONALS * Prepare the service plan for paraprofessionals * Supervise, and evaluate, the care given by the Personal care assistant, Companion and sitter as needed, as per Agency policy, for all clients including those that are identified as medically frail. * Submit, to the appropriate department/individual, a written evaluation of the paraprofessionals who are providing service to the clients, in his/her geographical area including yearly performance evaluations and direct observation or return demonstration of the tasks performed by the direct service employee * Participate in periodic conferences, with the paraprofessional supervisor, concerning the Aide's performance * Chart those services rendered to the client, by the staff nurse, and changes that have been noted in the client's condition and/or family and home situation, make revisions in the nursing service plan, as needed, record supervisory visits conducted with the paraprofessionals, evaluate client services and progress, and close charts of discharged clients * Evaluates the effectiveness of her nursing service to the individual and family * Consults with the attending physician concerning alteration of the service plan in consultation with the supervisor. ENVIRONMENT AND PHYSICAL REQUIREMENTS * Contact with clients under a wide variety of circumstances * Care is provided in client’s living environment with varying situations, including private homes, independent or assisted living or in an institution such as a hospital or long-term care facility. * May be required to respond to emergency situations. * Travel required. * Position includes tasks that have the potential for exposure to blood/body fluids/tissues and other potentially infectious material such as body fluids/tissues. JOB CONDITIONS * Must have a driver’s license and be willing and able to drive to client’s residences. * The ability to access clients’ homes which may not be routinely wheelchair accessible is required. Hearing, eyesight, and physical dexterity must be sufficient to perform a physical assessment of the client's condition and to perform and demonstrate client services. * Physical activities will include, walking, sitting, stooping, and standing and minimal to maximum lifting of clients and the turning of clients. * The ability to communicate both verbally and in writing is required as frequent communication by telephone and in writing is involved. EQUIPMENT OPERATION * Thermometer, B/P cuff, glucometer, penlight, hand washing materials COMPANY INFORMATION * Has access to all client medical records, personnel records and client financial accounts which may be discussed with the Nursing Coordinator QUALIFICATIONS * Must be a graduate from an accredited School of Nursing * Must be licensed, in Hawaii, as a Registered Nurse * One, or more, years of experience, in community/home care services Agency setting, or in a hospital setting is preferred. * Must have a working knowledge of agency care and the principles and techniques of professional nursing and required documentation that pertains to it * Should be skillful in organization and in the principles of time management and have knowledge of management processes * Must be able to contribute to the quality of care being rendered through constructive communication with nursing managers and staff * Must have a criminal background check * Must have a current CPR certification * The ability to communicate well, both, verbally, and in writing, in English, is required. 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