Completes an initial assessment of patient and family to determine home care needs.  Provides a complete physical assessment and history of current and previous illnesses Regularly re-evaluate patient nursing needs Uses health assessment data to determine nursing diagnosis Initiates and develops a Plan of Care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventative, and rehabilitative nursing care actions.   Includes the patient and the family in the planning process.  Makes necessary revisions as patient status and needs change Plans and implements patient health teaching and health counseling regarding the disease process(es), self-care techniques and prevention.  Counsels and involves the patient and patients’ family in accomplishing healthcare goals, meeting nursing and related needs while promoting patient/family independence Re-evaluates patient nursing care needs to include continuous assessment using the OASIS Data Set at appropriate time intervals during the episode Assesses the patient’s condition during every home health care visit; ensures assessments are communicated to the Clinical Team Manager (CTM) on a daily basis; nursing interventions are implemented to meet patient needs and changing conditions Initiates appropriate preventive and rehabilitative nursing procedures.  Administers medications and treatments as prescribed by the physician Identifies patient discharge planning needs as part of the Plan of Care development and implements prior to discharge of the patient Assumes responsibility to coordinate all patient care Recognizes and reports life threatening situations and responds appropriately Provides information regarding Home Medical Equipment (HME) and supply needs to the CTM, in a timely manner.   Utilizes equipment and supplies effectively and efficiently Performs care management duties for patients as assigned including:  notifying the physician of changes in the patient’s condition or progress toward goals, obtaining physicians orders as needed, reassessing the patient for recertification, attending and documenting case conferences, initiating coordination of care by reporting significant findings to others on the healthcare team, and planning for notification and documenting the discharge of the patient Adheres to the Agency’s Standard Operating Procedures as it relates to the submission of documentation Documents all communications with the patient, family, physician, CTM, pharmacy, and other disciplines, as indicated on communication notes Prepares a written plan for the certified Home Health Aide to follow, if applicable Established a trusting relationship with patients, caregivers, co-workers, clinic staff members, and physicians Demonstrates knowledge and observance of Patient Rights and Notice of Privacy Practices Follows all infection control standard precautions and safety guidelines/standards as per agency policy Participates in educational programs and all required in-service training programs to maintain comprehensive healthcare knowledge base, as assigned by supervisor Complies with all Homecare Dimensions, Inc. agency’s policies and procedures.  Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies.   Participates in the agency’s endeavors for accreditation, licensing, and professional recognition according to state, federal, and/or CHAP requirements.  Participates in the Performance Improvement Program activities of the agency and periodic review of clinical records, as assigned