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Registered Nurse - Home Health

OSS Health
Job Description
The Home Health RN is responsible for planning, coordinating, and documenting skilled professional nursing care provided to meet patient needs twenty-four (24) hours per day, seven (7) days/week for a geographically assigned caseload from the day of admission through day of discharge. Utilizing physician's orders and professional skills, the RN functions as a case manager and develops and implements a Home Health plan of care that meets each patient's specific needs and is in compliance with State and Federal Home Health regulations, reimbursement guidelines, as well as OSS Health At Home policies and procedures. The RN utilizes the nursing process which includes the use of technology, therapeutic intervention, evidence-based practice and coordination of care with other health team members to achieve positive clinical outcomes with the home health patients.  The Home Health RN is responsible for the on-sight supervision of the home health aide. The RN participates in weekend, holiday and on-call rotation and is able to carry a patient load of 5 to 6 visits per day.
Listing Category:
RN – Home Health
Requirements and Responsibilities:
Education & Qualifications
  • Education:  Graduate of an accredited nursing program, Bachelor’s degree in nursing preferred.
  • Experience: 
    • Level I:
      • Minimum of 2 years clinical nursing experience in general nursing, with Home Health experience preferred.
      • Level II:
        • Minimum of 3 years clinical nursing experience in general nursing, with Home Health experience required.
    • Demonstrates excellent written and verbal communication skills.
  • Licensure, Registration, and/or Certification:
    • Current license as a Registered Nurse in the Commonwealth of Pennsylvania.
    • Cardio Pulmonary Resuscitation (CPR) certification required.
    • Must be a licensed driver with an automobile in good working condition and have automobile insurance in accordance with PA laws.
Nursing Process
  • As a member of the OSS Health At Home team, the Registered Nurse utilizes the nursing process to contribute to each patient’s total plan of care.
  • Conducts initial nursing assessment through use of the OASIS assessment tool and including physical and psychosocial aspects, of patient/family/caregiver in a thorough, accurate, compassionate and timely fashion.
  • Utilizes own special body of knowledge to provide leadership and guidance to the home health team in formulating and individualizing the plan of care relative to the problems identified, interventions required and goals that must be addressed relative to the patient needs.
  • Contributes to identifying both active and potential needs of the patient and his/her family, which may affect the plan of care and refers other disciplines in to assist the patient/family as needed and required.
  • Consistently collaborates with the physician to plan and implement the medical and nursing plan of care.
  • Reviews the comprehensive plan of care with the home health team.
  • Communicates in writing in the chart and verbally with co-workers and supervisors to coordinate interventions and ensure continuity of care.
  • Facilitate and participate in team meetings and contributes to patient care planning.
  • Facilitate the implementation of nursing interventions and appropriate preventative and therapeutic nursing procedures through the provision of direct patient care and supervision of home health aide services.
  • Collaborate with other team members (physician, therapists, social workers and aides) to provide continuous assessment of assigned patients, interpret findings, initiate appropriate therapeutic actions, refer other disciplines and evaluate the results of these actions.
  • Accepts responsibility of assignment to perform a specialized procedure only when qualified with specialty training, proven competency, clinical background, and expertise in the specialty area.
  • Work in cooperation with family/caregiver and home health team members to meet the emotional needs of the patient, family and/or caregiver.
  • Provides appropriate information, teaching and explanation to the patient’s family regarding care. Facilitates patient and family education, to promote continuity of care and optimal patient/family outcomes.
  • Demonstrates expertise in the utilization of all team members.
  • Assists in the investigation and resolution of quality issues in conjunction with the Clinical Director.
  • Fulfill productivity requirements on an average daily census basis as determined by acuity level and Clinical Director. 
  • Document accurate complete and relevant clinical notes regarding patient’s condition and care given.
  • The Registered Nurse is a mentor who is able to provide educational experiences and communicate knowledge of patient care to members of the home health team including, but not limited to: patient and families/caregivers, other nursing staff, home health aides and the general community.
  • Act as a mentor who facilitates individual staff development from novice to expert. Participate in the orientation of new personnel and assist with field training as needed.
  • Identify the learning needs of the home health staff and other health care professionals, and facilitate formal and informal in-services, and patient care conferences to promote professional growth of all team members.
  • Teach patient/family/caregiver disease process and self-care techniques as appropriate. Provide medication, diet and other instructions as ordered by physician and recognize and utilize opportunities for health counseling of patient/family/caregiver.
  • Facilitate the development of teaching aids to promote patient/family/caregiver learning.
  • Evaluate effectiveness of educational experiences in order to promote ongoing professional development of home health staff and quality patient/family/caregiver outcomes.
  • Supervise the home health aides on-site per OSS Health At Home policies.
Time Management
  • The Registered Nurse oversees her caseload and responsibilities in order to support OSS Health At Home Home Health’s clinical and operational goals and objectives.
  • Coordinates patient care assignments and scheduling of visits so as to provide optimal patient care and efficiently organize care and services.
  • Visit frequencies are according to individual patient needs and acuity.
  • Visit frequencies are reviewed at least weekly and altered to meet patient needs and acuity.
  • Patient care visits will be coordinated with team members in order to utilize resources effectively and provide optimal patient care.
  • Participates in evening/weekend call as required, conducting on-call services in a clinically competent and responsive manner.
  • Maintains regular attendance.
  • Develops home health aide plan of care, introduces the home health aide to the patient/family and supervises the home health aides every fourteen (14) days or more frequently as needed to guarantee that the plan of care is implemented, followed and that patient/family are satisfied with the care and services being provided.
  • Ensures adequate and appropriate inventory of supplies and equipment for the provision of patient services and promotes the efficient use equipment and supplies.
  • Provides timely supervision and counseling of home health aides, which is constructive and encourages growth.
  • Strengthens problem solving ability of home health aides.
  • Maintains confidentiality in matters related to co-workers.
  • Demonstrates behavior appropriate to a role model and leader. Adheres to a code of conduct, conducive with OSS Health At Home policy.
  • Demonstrates creativity and critical thinking ability when developing patient care plans or completing assigned projects.
  • Assumes leadership role to facilitate care coordination and collaboration.
  • Functions without supervision, utilizing time constructively and organizing assignments for maximum productivity.
  • Collaborates with the home health team and effectively utilizes supervisor to problem solve.
  • Participates in agency meetings and activities as directed and requested.
  • Introduces self and clarifies role to patient/family/caregiver, physicians, facilities and referral sources.
  • Recognizes and responds appropriately to verbal and non-verbal cues.
  • Communicates effectively with all members of the home health team by:
    • Defending and supporting peer/team decisions and actions.
    • Asserting self with tact.
    • Supporting collaboration.
    • Maintaining open communication.
    • Offering suggestions and criticisms constructively.
    • Asking questions and sharing information during conferences.
    • Maintaining confidentiality in all areas.
  • Relates complete and pertinent information in verbal and written communication. Maintains clinical records, statistics, and reports as prescribed and in compliance with local, state and federal laws.
  • Initiates and maintains open and effective communication with Clinical Director, as well as other members of the home health team, as evidenced by improved patient outcomes.
  • Participates in the quality assurance/performance improvement process.
  • Facilitates active, ongoing problem solving, which reflects home health team participation.
  • Pursues problems to resolution, and/or refers them utilizing the appropriate chain of command.
  • Assumes responsibility for personal growth and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
  • Complies with local, state, and federal laws, Home Health Medicare regulations and established personnel policies and procedures.
  • Maintains all appropriate state nursing license requirements.
  • Conduct all business activities in a professional and ethical manner and adheres to OSS Health At Home’s code of conduct.
  • Meets or exceeds delivery of OSS Health At Home service standards in a consistent fashion.
  • Interacts with all staff in a positive and motivational fashion supporting OSS Health At Home’s mission.
  • Conducts all business in a professional and ethical manner.
  • Creates and maintains a professional atmosphere.
  • Complies with local, state and federal laws, Medicare regulations and established OSS Health At Home company policies and procedures.
  • The primary responsibility statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
  • Must maintain a professional attitude and demeanor and be able to communicate effectively and relate courteously and cooperatively with patients, caregivers, colleagues, supervisor, co-workers and all others. 
  • Must be able to demonstrate optimism, enthusiasm and willingness to work constructively with other health care team members and reflect concern for the well-being of patients and others.
  • Full-time
How to Apply:
  • To view and apply for our job opportunities, please go to our website osshealth.com and select - Join our Team!
Contact Information