• Home Care Registered Nurse (Per-Diem)

    Location US-NY-New York
    Posted Date 3 months ago(7/26/2018 3:43 PM)
    Job ID
    # Positions
    ArchCare Senior Life- Harlem
    Experience (Years)
    In-Home Services
    Work Days Per Week
    as needed
    Shift Start Time
    8:30 AM
    Shift End Time
    5:00 PM
    Per Diem
    # Hours
    as needed
  • Overview

    Responsible for providing home care nursing assessment and interventions along with care planning and coordination of 24 hour care for PACE participants as part of the PACE interdisciplinary team. Plans and supervises the personal care and ADL assistance tasks of Geriatric caregivers in the home. Makes visit to participant homes inpatient facilities and other location as require to assess participant level of care needs, coordinate with participants, family caregivers, other providers and the IDT. Work under general supervision.


    • Assesses participant’s physical and functional needs, along with psychosocial status and needs, home safety, family

         caregiver burden, ect utilizing professional knowledge, skills of observations and interviewing skills.

    • Completes assessment documents including DMS-1,SAAM, Problem lists and interventions and other documentation

         required for appropriate data collection and analysis as part of a quality assessment and performance improvement


    • Develops and implements the home care components and works with other team member to develops a comprehensive

         interdisciplinary team plan of care based on the needs of participants and caregiver, and goals mutually acceptable to                                                                  

              the participant/ family and significant others.

    • Monitors effectiveness and outcomes regularly and keeps the team informed as to participants progress and level of

              need. Remains alert to pertinent input from other team members, participants and family members/ caregivers.  

    • Reviews and revises goals and approaches to member/ family care coordination with interdisciplinary team members.
    • Provides initial home care assessments of new members enrolled in program, and reassesses at appropriate intervals according to PACE standards and the individualized needs of each participants in coordination with the IDT. Completes NYS required assessment tools according to the schedule planned by the IDT
    • Communicates with primary care providers and center nurses as needed to coordinates medication, ancillary tests and functions such as home blood draws as needed
    • Directs the provision of personal care, nursing rehabilitation tasks and other work of Home Aides and Geriatric Caregivers in the home.
    • Coordinates the medication delivery and administration processes for participants requiring assistance at home.
    • Coordinates with the Primary Care team on obtaining of Advance Directives; educated member/ family on their right to develop Advance Directives which may include Health Care proxy, Living Will, DNR Durable Power of Attorney and / or Burial Plans.
    • Educates and assesses the participants / family understanding of nursing needs and their capabilities for self care or family completion of allowable nursing tasks.
    • Documents changes in the participant’s condition and details care provided by completing all required PACE documentation and ensuring compliance to Agency standards and policies.
    • Travels to patient’s homes and/ or other facilities with varying environments ( e.g., elevated buildings, walk- ups, care facilities, single/ multiple family homes, presence of pets, ect.) using approved transportation options to deliver direct care to the participants as appropriate within the regulations.
    • Manages home care nursing planning for a caseload of participants. Maintains productivity sufficient to meet program goals.
    • Assists the interdisciplinary team members including the physician, as appropriate, in understanding the significant nursing, self care and functional needs related to the participant’s health problems.
    • Utilizes appropriates community resources and serves as a liaison between the program and other community agencies.
    • Provides nursing services in accordance with NYS Department of Education requirements and nursing scope of practice, agency policies, practices, and procedures.
    • Assumes responsibility for continued professional growth, such as in-service programs.
    • Participants in selected programs with community agencies.
    • Regularly informs the interdisciplinary team of the medical, functional, and psychosocial condition of each participants
    • Remains alert to pertinent input from other team members, participants and caregivers
    • Documenting changes of a participant’s condition in the participant’s medical record consistent with documentation

              policies established by the medical director                    

    • Participant’s in PACE and ArchCare Senior Life meetings including but not limited to, interdisciplinary team meetings, family meetings, staff meetings, in-service and training programs, rehab services and Quality Improvement activities.
    • Maintains flexibility in schedule and responds to unexpected emergencies and changes in workload in order to fulfill responsibilities
    • Performs other related duties, as required
    • Meet a standardized set of competencies for the special position description established by the PACE organization and approved by CMS before working independently.


    Formal Education

    ·         Associate’s degree


    ·         1 year

    License, Registration, and / or Certification Requirementyes

    Minimum Knowledge: Requires thorough knowledge of a specialized or technical field.

    Language Ability: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization



    Education Requirements



    ·         Associate’s Degree


    Education Desired



    ·         Bachelor’s degree in Nursing



    Experience Requirements


    ·         Minimum of one year of nursing experience in a health care setting One year of experience with a frail geriatric population in a long term care or home care setting.


    ·         Have 1 year of experience with frail or elderly population



    Experience Requirements

    ·         Appropriate additional experience in home care, long term care, PACE and / or MLTC.


    Skill Requirements


    ·         Customers Focus Planning and Problem Solving Accountable / Results Oriented Interpersonal Effectiveness Communications Integrity & Respect for others successful performance on clinical competency checklist for area of expertise CPR Certified.


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