Maintain annual HHRG values at the National Standard as appropriate.
Utilize HHRG values to establish visit frequency and to establish appropriate interdisciplinary utilization.
Annual outcomes meet National Benchmarks.
Refers to community resources as appropriate.
Evaluates the clinical needs of the patient; initiates, develops, implements and makes necessary revisions to the patient's plan of care; addresses all problems in the plan of care and documents accordingly.
Participates in inter-disciplinary patient case conferences; evaluates effectiveness of established plan of care.
Instructs and provides documented supervision of the Home Health Aide plan of care every 14 days.
Notifies MD/other involved care providers of significant changes in the patient’s condition.
Completes admission and other paperwork on a timely basis.
Records narrative documentation to reflect skilled care. Documentation is clear, concise and addresses specifics of teaching, direct care and response of patient / caregiver.
Obtains and clarifies valid MD orders for all care delivered.
Plans and coordinates discharges appropriately and informs patient/MD and records disposition of patient in the discharge summary. Completes all appropriate discharge paperwork.
All other duties as assigned.

Successful passage of VNA pre-hire medication test
Current RN license in Mass. and other related credentials to meet specialty.
Minimum one (1) year of nursing experience required or 6 months of nursing experience with a BSN.
CPR certification required.
Home care and IV experience, computer skills and BSN preferred.

RN (Per Visit), Martha's Vineyard, VNA of Cape Cod

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