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1.     Provides services requiring substantial and specialized nursing skill, in accordance with the plan of treatment signed by the physician and makes the initial evaluation visit to the client.  Accepts only clients referred by the client care manager or designee.  Demonstrates competency in all skills required for the agency, including, but not limited to, venipunctures, infusion therapy, infusion therapy device care, wound care and aseptic technique.

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2.     Evaluates, and regularly reevaluates, the nursing needs of the client; initiates, develops, implements and makes necessary revisions to the client’s plan of care.  Assesses the client’s continual care needs.  Addresses all problems in the plan of care or documents rationale for not doing so.

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3.     Initiates diagnostic, preventive and rehabilitative nursing procedures as appropriate to the client’s care and safety.  Makes referrals to other disciplines as indicated by the client’s needs or documents rationale for not doing so.

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4.     Observes signs and symptoms and reports to the physician and/or other appropriate health professionals as often as needed, or upon changes in the client’s condition.

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5.     Teaches, supervises and counsels the client and family regarding home nursing procedures and other care needs as appropriate to the client’s condition.  Utilizes agency educational material as appropriate.

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6.     Coordinates the total plan of care and maintains continuity of client care by liaising with other health professionals assigned to the same clients.  Attends client care conferences.  Initiates client care conferences for complex and/or multidisciplinary clients whenever needed.

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7.     Supervises and teaches the home health aide.  Every two weeks, assesses the client’s need for unskilled care and revises the plan of care as appropriate.  Communicates the plan of care changes to the aide and scheduler as often as necessary.

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8.     Develops, prepares and maintains individualized client care progress records with accuracy, timeliness and according to policies.  Submits accurate documentation within 24 hours of visit.

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9.     Responsible for following all policies and procedures of the agency regarding service delivery, documentation and care coordination.  During supervisory visits, exhibits full compliance and verbalizes knowledge of agency policies including but not limited to client education, infection control, management of hazardous wastes and age-specific behaviors for clients.

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10.   Participates in the agency’s quality improvement program.

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11.   All other duties as assigned.