A nurse currently licensed and registered in the state of practice, which provides professional services within the scope of nursing practice standards in collaboration with primary care physicians, teaches and educates patients and their families. Professional skilled nursing is performed under the supervision of the Administrator/Director of Nursing.

Qualifications:

• Graduate of an approved professional nursing program (RN)
• Currently, licensed “in good standing” in PA
• Minimum of one (1) year of experience as a professional nurse, preferably in home care
• Must have a criminal background check
• Must have current CPR certification

Responsibilities:

• Furnishes those services requiring substantial and specialized nursing skill
• Initiates appropriate preventative and rehab nursing procedures
• Prepares & submits timely, clinical and progress notes
• Oversees coordination of patient services
• Informs MD and other staff of changes in PT situation or needs
• Completes medical history/home safety check/environmental assessments
• Performs socio-psychological evaluation
• Performs assessment visit and documents timely. (ie. OASIS/ Skilled Nursing Note etc.)
• Performs physical examination and review of all body systems and documents accordingly
• Develops individualized Plan of Care (POC) to be submitted to the physician for approval and implementation and performs necessary revisions based upon patient needs
• Determines medical necessity for other services
• Regularly re-evaluates the patient’s nursing needs
• Evaluates the patient’s ADL and iADL abilities and need for home health aide
• Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan the beginning of each certification period
• Supervises HHA in accordance with state/federal requirements and documents the supervision
• Orders “other” professional services that may be appropriate to the needs
• Reviews billing processes with patient and/or family advising patient and/or family when co-pay or Medicare is not likely to pay for services
• Effectively communicates ongoing with patient and family progression/changes in POC
• Effectively communicates with Supervisor/Nursing Director/other disciplines in the case
• Communication with the patient’s MD (verbally and/or in writing) to obtain effective treatment modalities and/or rehabilitative therapy modalities
• Actively communicates in the case conferencing sessions to establish best practices
• Submits requests for re-authorization of “more visits needed” to payers timely
• Coordinates Community Services for the patient to assist in safe home care needs
• Participates in the Performance Improvement Committee process
• Performs timely clinical record reviews (CRR) per Agency policy in collaboration with the Nursing Supervisor
• Participates in ongoing staff meetings/in-services
• Participates in the growth of office by being a willing preceptor for same discipline employees
• Participates in the planning, operation and evaluation of the nursing services of the organization
• Maintains professional licensure per state requirements
• Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the patient caseload as quickly as possible relative to the event’s occurrence
• Submits written time requests 2 weeks or more in advance of planned time off
• Other duties as assigned

A Licensed Practical Nurse (LPN) currently licensed and registered in the state of practice, who provides practical nursing skills within the scope of nursing practice standards in collaboration with RN case managers/supervisors, teaches and educates patients and their families according to the established professional plan of care. Licensed Practical nursing is performed under the supervision of the assigned RN’s, Administrator, and Director of Nursing.

Qualifications:

• Graduate of an approved LPN nursing school
• Currently, licensed “in good standing” in PA
• A minimum of one (1) year of experience as a licensed practical nurse, preferably in a home care setting
• Must have a criminal background check
• Must have current CPR certification

Responsibilities:

• Maintains the nursing frequency established by the supervising RN
• Follows the plan of care established by the supervising RN
• Prepares equipment & materials for treatments observing aseptic techniques as required
• Performs home safety check and environmental check of the patient’s home environment on all visits. Reports any unsafe or potentially unsafe condition to the supervising RN
• Performs nursing visit and documents accordingly (Skilled Nursing Note etc.) Uses care to always sign credentials anywhere a nursing signature is needed
• Reviews and follows the supervising RN’s plan of care, communicating frequently with the supervising RN on any suggested changes necessary
• Collaborates with the supervising RN on a weekly (or more frequent basis) to benchmark toward the established outcome goals
• Reviews the patient’s ADL and iADL abilities and therefore need of support services such as home health aide. Communicates any suggested changes to the supervising RN
• Teaching patients & family self-care techniques
• Reinforces the HHA plan of care when HHA services are ordered
• Effectively communicates with patient and family the POC and progression of such. Keeps the patient informed ongoing
• Effectively communicates with other disciplines in the case (actively participates in case conferencing) to effectively and appropriately problem solve as situations arise
• Communicates effectively with the supervising RN, scheduled visits planned and changes to the schedule on a weekly basis. Caseload is self-scheduled but communication of the clinician’s schedule to the nursing supervisor is essential
• Communicates in case conferencing sessions
• Effectively functioning as an involved team member to collaborate on best practices for the individual patient’s needs
• Submits accurate, complete paperwork at the end of every week so that all medical records are intact and up to date. Uses the drop box if the office is already closed for the weekend
• Notifies the supervising RN with requests for re-authorization of “more visits needed” prior to third party insurers authorized number of visits expiring
• Suggests Community Services that may be available to the patient to assist in safe home care needs
• Understands that the fiscal and clinical management of each case is directly linked to the success of his/her office. Assures that visits are not done that cannot be billed
• Participates in the QA Committee process as requested to do so
• Participates in the monthly staff meeting as part of the requirements of the position; Adjusts visits on the staff meeting day to accommodate this important function
• Participates in the growth of the office by being a willing preceptor for newly hired, same discipline employees
• Maintains LPN licensure and actively seeks out educational experiences to enhance the practice of home care nursing for her/him and the benefit of the patients serviced
• Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the patient caseload as quickly as possible relative to the event’s occurrence
• Submits written time requests 2 weeks or more in advance of planned time off

The home health aide provides personal care and related services in the home. She/he functions under the direction, instruction and supervision of the staff nurse and the Director of Nursing and/or appropriate supervisor.

Qualifications:

• Prefer Completion of the 9th grade; prefer high school graduate or equivalent
• Ability to read and write in English, consistent with job requirements
• Has a reliable means of transportation to get to assigned patient visits
• Must have a criminal background check and current CPR certification
• Meets one of the following:
1. A home health aide training and competency evaluation program as specified by CMS in the CoP § 484.80 (b) and (c) respectively, OR
2. A competency evaluation program that meets CMS specifications, OR
3. A nurse aide training and competency evaluation program approved by the state as meeting the requirements of 42 CFR 483.151-154, OR
4. The requirements of a state licensure program that meets the provisions of CMS Home Health CoP § 484.80 (b) and (c)

Responsibilities:

• To assist with ADLS and iADLs as per the POC
• To follow the POC for each patient and document the same
• Helps the patient to maintain good personal hygiene
• Assists in maintaining a healthful, safe environment
• Plans and prepares nutritious meals; Markets when indicated on the POC
• Assists the patient with ambulation as per the POC
• Assist with certain treatments as directed by the skilled nurse
• Assists the therapy personnel as needed with rehabilitative processes
• May cue for medications ordinarily self-administered as assigned
• Taking and charting vital signs under the supervision of nursing staff
• Encourages the patient to become as independent as possible according to the nursing care plan
• Attempts to promote patient’s mental alertness through involvement in activities
• Gives simple emotional and psychological support to the patient and other members of the household
• Establishes a relationship with patient and family which transmits trust and confidentiality
• Prepares a report of her visit on the day it is performed and incorporates same in the clinical record weekly or as directed
• Reports any change in the patient’s status or home situation to her immediate supervisor, the staff nurse, or the aide supervisor, including recognizing & reporting skin changes
• Carries out their assignment as instructed by the nurse or the paramedical team and documents and reports to the nurse when she is unable to do so
• Works with personnel of other community agencies involved in the patient’s care as directed by the staff nurse
• Performs routine housekeeping tasks as related to a safe and comfortable environment for the patient, as instructed by the professional nurse
• An active participant on the interdisciplinary team & QA program
• Attends in-service as required by state and federal regulations
• Confirming on a weekly basis, the scheduling of visits with the Supervisor/Director, to coordinate necessary visits with other personnel
• Notifying the agency of absences due to illness, emergency leave, normal vacation periods, or special professional meetings, which will affect agreed service with the agency
• Wears the agency’s name badge at all time they are seeing agency patients

The CNA provides personal care and related services in the home and functions under the direction, instruction and supervision of the staff nurse and the DPS and/or appropriate supervisor.

Qualifications:

• Prefer Completion of the 9th grade; prefer high school graduate or equivalent
• Ability to read and write in English, consistent with job requirements
• Completion of a qualified, state approved training program consistent with state and federal requirements and for which a CNA certificate was obtained
• Satisfactory performance on a competency evaluation
• The emotional and mental maturity necessary for establishing and maintaining a good work relationship with the patient, patient’s family, and the personnel of the agency
• Reliable means of transportation to get to assigned patient visits
• Current CPR certification
• Must have a criminal background check & other checks as required

Responsibilities:

• To assist with ADLS and iADLs as per the POC
• To follow the POC for each patient and document the same
• Helps the patient to maintain good personal hygiene
• Assists in maintaining a healthful, safe environment
• Plans and prepares nutritious meals; Markets when indicated on the POC
• Assists the patient with ambulation as per the POC
• Assist with certain treatments as directed by the skilled nurse
• Assists the therapy personnel as needed with rehabilitative processes
• May cue for medications ordinarily self-administered as assigned
• Taking and charting vital signs under the supervision of nursing staff
• Encourages the patient to become as independent as possible according to the nursing care plan
• Attempts to promote patient’s mental alertness through involvement in activities
• Gives simple emotional and psychological support to the patient and other members of the household
• Establishes a relationship with patient and family which transmits trust and confidentiality
• Prepares a report of her visit on the day it is performed and incorporates same in the clinical record weekly or as directed
• Reports any change in the patient’s status or home situation to her immediate supervisor, the staff nurse, or the aide supervisor, including recognizing & reporting skin changes
• Carries out their assignment as instructed by the nurse or the paramedical team and documents and reports to the nurse when she is unable to do so
• Works with personnel of other community agencies involved in the patient’s care as directed by the staff nurse
• Performs routine housekeeping tasks as related to a safe and comfortable environment for the patient, as instructed by the professional nurse
• An active participant on the interdisciplinary team & QA program
• Attends in-service as required by state and federal regulations
• Confirming on a weekly basis, the scheduling of visits with the Supervisor/Director, to coordinate necessary visits with other personnel
• Notifying the agency of absences due to illness, emergency leave, normal vacation periods, or special professional meetings, which will affect agreed service with the agency
• Wears the agency’s name badge at all time they are seeing agency patients

A person, who under professional supervision, provides assistance with nutritional and environmental support, personal hygiene, feeding and dressing.

Qualifications:

• Has successfully completed one of the following:
1. Demonstrated competency by passing a competency exam developed by the Agency or other entity which meets the PA regulatory requirements
2. A training program developed by the Agency that meets all the PA state requirements
3. A training program meeting the training standards by virtue of the agency’s participation as a provider in a Medicaid Waiver or other publically funded program providing home & community based services
4. Another program identified by the PA DOH by subsequent publication in the PA Bulletin or on the DOH website
• Shows an interest and concern for people, good judgment and tact in dealing with the sick
• Practices good hygiene and is neat in personal appearance
• Speaks, reads, and writes English
• Must have current CPR certification
• Must have criminal background check

Personal Care Assists With:

• Bath (tub, shower or bed)
• Oral hygiene
• Grooming and care of hair
• Ordinary care of nails
• Routine skin care/lotion massage
• Positioning and turning of patents that cannot assist self- in bed and chair
• Elimination
• Assist with eating, dressing walking and toileting
• Remind patient to take medications

Homemaking Assists With:

• Meal planning and preparation in accordance with complex and modified diets
• Feeding the patient
• Linen change (occupied and unoccupied)
• Laundry, patient’s only
• Light housekeeping; washing dishes, clean kitchen, dust & vacuum, only those rooms the patient uses
• List needed supplies and grocery shopping

PCAs Are Required To:

• Follow universal precautions whenever giving any aspect of patient care
• Maintain confidentiality
• Perform ONLY those functions specified for each individual patient on the POC
• Respond to the physical, emotional and development needs of patients
• Follow emergency procedures in the event of any incident, e.g., accident, injury or significant change in patient’s condition

Essential Administrative Functions:

• Follow patient rights at all times
• Record each activity performed on each case on a daily basis
• Report any incident or change in condition of patient or environment immediately
• Submit Daily Activity Sheets and record accurately on a timely basis (WEEKLY)
• Follow instructions, is punctual and is at work as scheduled
• Follow all appropriate agency policies
• Attend in-service education annually per agency policy
• Provide all information required for the maintenance of her/his personnel record as per state regulations
• Show interest, asks questions and seek help as indicated; is receptive to supervision
• Develop relationships and is cooperative with patient, family and supervisor
• Maintain appropriate appearance
• Is productive and uses time efficiently
• Follows instructions, is punctual and attendance is acceptable
• Cooperates with supervisor and with patient/family
• Is self-reliant and plans appropriately
• Other duties as are reasonably assigned

The homemaker is a paraprofessional employee, trained to provide, home maintenance services for patients under the direct supervision of the nursing supervisor. Homemaking services include dietary management, household services essential to the patient’s health and wellbeing, and provision of and instruction in reporting of signs, symptoms, and/or changes in the patient’s condition. The homemaker is assigned to a patient by the coordinator and is given a written assignment sheet.

Qualifications:

• Successful completion of at least 40 hours of generic training to be completed by the end of the 6th month of employment (can be done by shadowing/precepting) or verification of homemaking services provided in the community equivalent to 40 hours
• Use of an automobile with possession of liability insurance is desirable
• Must be able to read, write and follow instructions in English
• Selected on the basis of such factors as: an interest in people, tact, dependability in employment, neatness in appearance/practices, good personal hygiene, and good judgment
• One (1) year of work experience
• Must have a criminal background check
• Must have current CPR certificate

Responsibilities:

• Shopping with an effort to economize and preparation of nutritious and appetizing meals
• Assisting with simple health care routines such as reminders to maintain diet restriction, medication regimen, and recommended exercises and cueing to take meds
• Observation, and feedback to the coordinator/nursing supervisor on patient’s behavior, mood, and adjustment in the home
• Being supportive and encouragement during periods of loneliness, depressions, bereavement etc.
• Providing routine housekeeping tasks, which are required
• Caring for clothing, washing, drying, folding and putting away
• Follows the POC for housekeeping tasks
• Records observations and tasks and signs each entry on the appropriate form for each visit made
• Communicates on a weekly basis or more often as necessary with the nursing supervisor
• Immediately reports emergency situations by phone to nursing supervisor or office
• Keeps an accurate time and mileage report
• Follows assignments and regulations
• Follows specific office orders for each patient
• Uses homemaker policy manual as guidelines
• Works within the organizational channel of authority and knows the area of responsibility of all other team members
• Wears appropriate clothing and ID badge when at work

Confirming on a weekly basis, the scheduling of visits with the Supervisor/Director, to coordinate necessary visits with other personnel.

Notifying the Agency of absences due to illness, emergency leave, normal vacation periods, or special professional meetings, which will affect agreed service with the Agency.

The Companion is a paraprofessional, providing visitation, support and companionship in the home for patients under the direct supervision of a qualified supervisor. Companion services include support, encouragement, companionship, respite breaks for family or caregivers, and provision of and instruction in reporting of signs, symptoms, and/or changes in the patient’s condition. The Companion is assigned to a patient by the coordinator and is given a written assignment sheet.

Qualifications:

• High School graduate with at least 1 year experience as a companion or life working experience
• Complete an Agency training/orientation program
• Effective interpersonal communication skills
• Get along well with people and exercise good judgment
• Use of an automobile with possession of liability insurance is desirable
• Must be able to read, write in English and follow instructions
• Selected on the basis of such factors as: an interest in people, tact, a history of emotional stability, dependability in employment, neatness in appearance and practices, good personal hygiene, and good judgment
• Must have a criminal background check

Responsibilities:

• Provide respite breaks for family or caregivers
• Provide assistance with reading and writing correspondence and publications
• Observation and feedback to the coordinator/nursing supervisor on patient’s behavior, mood, and adjustment in the home
• Notifies superior of any safety issues
• Being supportive and encouragement during periods of loneliness, depressions, bereavement etc.
• Follows the care plan for tasks
• Records observations and tasks and signs each entry on the appropriate form for each visit made
• Communicates on a weekly basis or more often as necessary with the nursing supervisor
• Immediately reports emergency situations by phone to nursing supervisor or office
• Keeps an accurate time and mileage report
• Follows assignments and regulations
• Follows specific office orders for each patient
• Uses policy manual as guidelines
• Works within the organizational channel of authority and knows the area of responsibility of all other team members
• Wears appropriate clothing and ID badge when at work

Confirming on a weekly basis, the scheduling of visits with the Supervisor/Director, to coordinate necessary visits with other personnel.

Notifying the Agency of absences due to illness, emergency leave, normal vacation periods, or special professional meetings, which will affect agreed service with the Agency.