Job Summary: Promotes and maintains the health of enrolled participants through nursing assessment, treatment, teaching and counseling.  Responsible for completing enrollment and periodic assessments of health needs to contribute to the individual’s plan of care. Responsible for the implementation of nursing care plan and coordination of nursing with other services.   

Primary Responsibilities:  Under limited supervision and in accordance with all applicable federal, state and local laws/regulations:

1. Completes RN assessment during initial, semi-annual, annual and significant change evaluations
2. Ensures participants care plan is reflective of all nursing interventions and participant diagnoses
3. Initiates preventative nursing care procedures as appropriate for the participants’ care and safety
4. Completes participant cares scheduled within the day center and in participants’ homes as needed
5. Collaborates with the Home Care Nurse about teaching needs of participants and families 
6. Implements, directs, evaluates and provides oversight of nursing care and care provided by certified nursing assistants. 
7. Collaborates with provider to facilitate PACE appointments, participant needs and plans/follow-up for specialty appointments and medical orders
8. Assists with preparation for interdisciplinary team meetings and ensuring that all updates for participants and needed appointments are added to the schedule 
9. Communicates regularly with pharmacy regarding prescription changes and ensuring that participant MAR is up to date
10. Provides care to participants in a positive, nurturing, professional manner. 
11. Provides health teaching to participants with complex nursing needs
12. Triages and ensures assessments are completed on participants reporting any sudden illness or onset of illness at home.
13. Is flexible and able to adjust schedule to meet complex needs of participants.
14. Consults with other staff members regarding any concerns about appointments, complaints or other anticipated/discovered needs identified during assessments.
15. Works with social worker regarding family and caregiver in caring for homebound participants.
16. Maintains accurate records of all nursing services provided to participant in EMR
17. Participates in Quality Improvement activities as requested
18. Collaborates with hospital for any participant hospitalized
19. Collaborates with nursing facility weekly for any participants residing in nursing facility

Employment Specifications: