Summary

The Registered Nurse provides skilled nursing care to home health patients in their homes under a physician or allowed practitioner plan of care. The RN completes comprehensive assessments, including OASIS, develops and revises the plan of care, coordinates services, and supervises home health aides and LPNs. The RN works under the direction of the Clinical Supervisor and follows Medicare Conditions of Participation, Florida AHCA rules, Joint Commission standards, and Matrix Care LLC policies.

Essential Functions

Patient Care

1.      Completes start of care, resumption of care, recertification, transfer, and discharge assessments within required timeframes, including a physical assessment and history of current and prior illness.

2.      Assesses the home environment, safety, fall risk, caregiver support, and psychosocial needs.

3.      Completes medication reconciliation at each assessment and identifies drug interactions, duplications, and adherence issues.

4.      Develops and revises the individualized plan of care with measurable goals, including the patient and family in planning.

5.      Provides skilled nursing interventions, medications, treatments, and wound care as ordered.

6.      Teaches patients and caregivers on disease management, medications, safety, and when to seek help.

7.      Identifies discharge planning needs early and implements them before discharge.

8.      Acts as case manager for an assigned caseload when designated by the Clinical Supervisor.

OASIS and Documentation

1.      Completes OASIS accurately using the current CMS version, following CMS guidance on coding.

2.      Documents each visit in the EMR (KanTime) per agency timeliness standards [confirm: e.g., within 24 hours].

3.      Uses electronic visit verification as required.

4.      Supports accurate PDGM coding, functional scoring, and quality outcomes through complete documentation.

5.      Responds to QA and coding review requests by the agency deadline.

Communication and Coordination

1.      Reports changes in condition to the physician or allowed practitioner and the Clinical Supervisor promptly, and obtains and documents orders.

2.      Coordinates care with therapists, aides, MSWs, physicians, pharmacies, DME vendors, and community resources.

3.      Participates in case conferences and interdisciplinary care coordination.

4.      Arranges needed equipment, supplies, and services.

Aide and LPN Supervision

1.      Instructs and supervises home health aides, completing onsite supervisory visits at least every 14 days for patients receiving skilled services, and annually with the aide present.

2.      Prepares and updates written aide care plans.

3.      Directs and oversees LPN care within Florida scope of practice.

4.      Reports aide or LPN performance concerns to the Clinical Supervisor.

Quality, Safety, and Compliance

1.      Follows Joint Commission National Patient Safety Goals, including two patient identifiers, medication safety, infection prevention, and fall risk reduction.

2.      Follows infection control, emergency preparedness, and HIPAA policies.

3.      Explains patient rights, responsibilities, and the complaint process.

4.      Reports suspected abuse, neglect, or exploitation as required by Florida law.

5.      Reports incidents and participates in quality improvement (QAPI) activities.

Additional Duties

1.      Participates in on-call rotation per agency policy.

2.      Completes orientation, annual competencies, and required in-services.

3.      Performs other related duties as assigned.

Requirements

Qualifications and Requirements

Required

1.      Active, unrestricted Florida RN license or multistate (compact) license valid in Florida.

2.      Graduate of a state-approved school of nursing.

3.      Current CPR/BLS certification.

4.      Minimum one year of RN clinical experience.

5.      Clear Level 2 background screening per Florida law, plus agency health screening.

6.      Valid Florida driver's license, reliable transportation, and auto insurance meeting agency minimums.

7.      Completes skills competency checklist before independent practice.

Preferred

1.      BSN.

2.      One or more years of home health experience.

3.      OASIS experience; COS-C or HCS-D certification.

4.      Bilingual English and Spanish.

Skills

1.      Strong assessment, clinical judgment, and documentation skills.

2.      Able to work independently and manage a caseload with minimal supervision.

3.      Clear verbal and written communication with patients, families, and physicians.

4.      Comfortable with EMR, tablet, and mobile documentation.

Physical Demands and Work Environment

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

•     Regular driving between patient homes, often several visits per day.

•     Prolonged standing, walking, bending, stooping, kneeling, and reaching.

•     Lift and carry up to 50 lbs; assist with patient transfers and positioning using proper body mechanics and devices.

•     Vision and hearing sufficient for assessment, documentation, and safe driving.

•     Work in patient homes with variable conditions, including pets, stairs, and limited space.

•     Possible exposure to infectious diseases, bloodborne pathogens, and hazardous materials; PPE provided.