Provides comprehensive post-acute in-home healthcare to eligible patients residing on Tribal trust lands. All RN skilled services are provided in accordance with physician orders as well as federal, state, and Tribal criteria for each program. Performs a variety of highly skilled specialized nursing duties to include clinical procedures, specified lab test, head to toe assessments, patient and caregiver education and all associated documentation. 80% of the Staff RN time is spent in the home delivering one-on-one patient care. All related activities are in compliance with the NC Nurse Practice Act.
- Responsible for assessing each patient based on in-home need and safety with focus on the appropriate Tribal program to best meet that need; programs include but are not limited to Skilled Home Health Care, Chronic Disease Management, or Hospitalization prevention.
- 80% of daily duties involves providing direct hands-on nursing care including clinical procedures, patient and family education, administration of medications, assessments of total health through the implementation and evaluation of the Medical Plan of Treatment.
- Makes the initial assessment visit and comprehensive assessment within 24-48 hours unless otherwise ordered by the provider.
- Completes all required forms in compliance with CMS and Tribal standards/criteria.
- Completes admission education and teaching with the patient and caregiver during the admission assessment.
- Develops and implements the multidisciplinary plan of care with involvement of the patient, caregiver, other disciplines, and the primary provider. Documents verbal orders from providers within the same day. Documents Transfer and Discharge information per CMS and ACHC standards of best practice.
- Recognizes and informs the RN supervisor of unusual or difficult in-home health care issues and utilizes problem solving skills to construct/suggest changes to the in-home plan of care.
- Recognizes abnormal lab results and or changes in the patient condition. Notifies the primary provider per agency policy, always advocating for the best interest of the patient.
- Makes written referrals to other disciplines as needed based on assessment and identification of needs in the home.
- Maintains electronic and written schedules coordinating patient care, assembling supplies, prioritizing patient visits using time management skills and technique.
- Performs CNA supervisory visits for Home Health patients per CMS Conditions of Participation. Updates the CNA plan of care when needed to optimize patient outcomes and best practice.
- Required to work on holidays, weekends, and after hours to fulfill on-call duty as certain sectors of in-home health care operate 24/7.
- May be required to takes breaks and lunch time in the patient home pending the needs of the patient and caregiver, following industry standards of home care.
- Participates in Pl committee as designated by the RN Supervisor and completes quality improvement projects as assigned.
- Cleans nursing equipment after each patient use and cleans supply bag at least monthly using OSHA standard precaution practice.
- Ensures that all medical supplies are current and without issue prior to using on a patient.
- Completes all required documentation electronically and written per program criteria, CMS, and ACHC regulations.
- Demonstrates safe practices using proper body mechanics, following policies for sharp/dangerous material handling and disposal and reporting and or acting to correct unsafe practice.
- Attends all mandatory in-service/educational programs and staff meetings as instructed.
- Attends at least 16 hours of work-related education annually.
- Expected to obtain continuing education both through in-service training and self propelled training modules both in- house and on location.
- In the event of a public health emergency, employee may be reassigned to a duty station to ensure safety and treatment are delivered to the public as quickly as possible.
- Comes to work as scheduled and consistently demonstrates dependability and punctuality.
- Perform job duties according to established safety guideline and Tribal policies.
- May be required to remain at work or report to work during times when admin leave is granted in order to meet the needs of patient's and program operations
This position is supervised by program leadership. This position is not responsible for supervising others.
Experience: One (1) year of related experience required. Experience to include Home Health and electronic medical record - point of care.
Education: Associate’s Degree in Nursing is required. Home Health OASIS training within 1 year of employment required.
Licenses & Certifications: Valid, insurable NC Driver’s License required. Current unrestricted RN licensure in the State of North Carolina per NC Board of Nursing guidelines, in good standing without a substantiated history of abuse, neglect, misappropriation or violation of patient's rights. CPR/First Aid certification.
- Must have a thorough knowledge of the policies, procedures, and guidelines of EBCI PHHS Division and Tribal In-home care Systems, standards nursing practices, applicable OSHA mandates, and related regulatory controls such as ACHC, CMS, DMA, and DHHS.
- Knowledge regarding home health care with expertise in clinical issues required.
- Must have an understanding of the EBCI culture, lifestyles, and risk factors.
- Requires knowledge of the geography of the assigned area.
- Knowledge regarding in-home care industry standard and expertise in clinical/coverage and issues required.
- Must maintain current, unrestricted RN licensure, CPR/First Aid certification and proof of automobile liability insurance, without lapse.
- Must be proficient in Microsoft Office Suite.
- Nine (9) to twelve (12) months would be necessary to become proficient in most phases of this position.
* Disclaimer Statement
This is not intended to be an all-inclusive list of job-related responsibilities, duties, skills, requirements or working conditions. Other duties may be assigned based on business need and the supervisor’s request.
EBCI reserves the right to revise the position description at any time. Designated positions may be required to assist in emergency and/or disaster situations. Complete job description is found on application site.
Public Health & Human Services
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