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• 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.