Registered Nurse - Anna, United States - Community Integrated Living Incorporated

Description

Job Description

$3,000 Sign On Bonus

1099 Contract - $130 per resident, per month, residents total.

Job Summary:

The Registered Nurse (RN) is responsible for providing and coordinating optimum client care by utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation; and effectively interacts with clients, significant others, and other team members while maintaining standards of professional nursing.

Essential Functions:

1. Client assessment – development nursing data by observing, interviewing, and collecting data from the clients and other sources.
2. Set priorities for nursing action according to client needs and formulate a plan of care taking into account physiological, psychosocial, and environmental factors.
3. Evaluate client condition with ongoing assessment.
4. Document accurate and ongoing assessment of incidental change or incidents on each client.
5. Communicate with the physician regarding client needs.
6. Administer medications as ordered according to policy and procedure.
7. Administer treatments as ordered according to policy and procedure.
8. Receive and accurately transcribe physician orders according to policy and procedure.
9. Respond to emergencies and follow through as needed.
10. Maintain a clean, neat and safe environment for clients and staff.
11. Ensure that supplies and equipment necessary for client care are stored in an organized and efficient manner.
12. Client visits in the CIL homes as needed for issues/illnesses/concerns
13. Communicate ALL appointments with HM and ED to ensure no appointments are missed (to meet state regulations)-usually 3 days per week
14. Contact and reschedule medical appointments if conflicts exist
15. Contact guardians as needed to communicate medical/nursing issues
16. ALL medical appointments (medical, dental, eye, mammogram, derm, etc) faxed to me; these are entered into the client annual nursing summary (state requirement)
17. Maintain up to date nursing summaries on each client-readily available in case of emergency
18. Maintain up to date med list on annual nursing summary to reflect current medications and medications discontinued over past year
19. Enter all lab results in each client nursing summary for an accurate picture of past year's results

20. Review meds in med cart to ensure all meds appropriate, not outdated, and only current meds are in cart

21. Communicate with pharmacy any medication additions, discontinued meds, administration time changes

22. Complete prior authorizations as needed for medications to be paid for

23. Generate, sign, and fax med training sheets (done very frequently) for any med changes (initiation of new med, change in dose, or discontinuation of med). NO med changes can occur without these sheets completed by me. Present during Rule 116 state surveys to provide documentation, communicate with surveyors and answer questions.

24. Rounds in each home weekly

25. Review MARS in each home to ensure all meds have been passed and documented weekly

26. Review MARS to ensure all PRN meds are appropriately followed up on weekly

27. Review med training sheets to ensure all med trained staff have signed them; bring them to office for filing (required by state) weekly

28. Assess/see each client to determine any issues/concerns weekly

29. Address any staff concerns

30. Relay concerns to HM, QIDP, ED, Physician as needed

31. Weekly injection of Trulicity to client

32. Collect, review, and enter monthly vital signs and weights on all clients (multiple messages sent to HM to have these sent)

33. Prepare client list for rounds and send to physician and HM (state requirement) monthly

34. Collect appropriate paper work from HM for rounds; review and prepare documents for rounds (done for each client in each home on a rotation to meet state requirements) monthly

35. Review and sign new MARS each month for each client and distribute to HM

36. Review and sign new physician order sheets for each client, obtain signature of physician, and bring to CIL office monthly

37. Review and sign MARs from previous month to ensure all signatures of med trained staff are present, there are no unsigned meds, and all PRN meds are followed up as required by state

38. Update client information in the state required HRST program for those clients due for IDT.

39. Complete annual nursing summary for those clients due for IDT.

40. Complete medical portion of Specific Level of Functioning (SLOF) for those clients dual diagnosed due for IDT.

41. Print state required HRST reports, SAMAS, and annual nursing reports due for IDT for the month and bring to CIL office as needed

42. Complete required quarterly SAMA reports in the state HRST program-print them as required for client charts as needed

43. Assess clients that are dual diagnosed for quarterly SAMA report quarterly

44. Review and enter quarterly labs in client nursing summaries

45. Communicate with physician any abnormal lab values, receive additional orders for medications, additional labs, diet changes, etc-write orders as appropriate to address abnormal labs

46. Prepare and submit quarterly medication report as required by state to CIL office

47. Evaluate and assess those clients on psychotropic medications using the DISCUS scale to ensure no tardive dyskinesia is present (state requirement) every 6 months

48. Notify physician, guardian, QIDP, ED, HM if tardive dyskinesia is present (med changes may be needed)

49. Annual recertification for each med trained DSP at no charge (paperwork required to be completed to meet state guidelines)

50. Completion of med certification after med class: go to facility and observe med pass by DSP, complete appropriate state required forms and take to office for filing

51. Complete and submit annual nursing summaries and give to QIDP

52. Update state required HRST packet annually

53. Generate new SAMA report in state required HRST annually

54. Print all documents and submit to QIDP as needed

55. Write policies related to COVID, Infection Prevention, Medication Administration, etc

56. Participate in economical utilization of supplies.

57. Follow all policies and procedures, and other regulatory standards.

58. Communicate with clients, family and significant others with concern and empathy in a respectful manner.

59. Attend monthly staff meetings as scheduled.

60. Attend mandatory meetings as scheduled.

61. Assist in the orientation/training of new team members.

62. Consistently work in a positive and cooperative manner with co-workers.

63. Perform tasks which are supportive in nature to the essential functions of the job but which may be altered or redesigned depending upon individual circumstances.

64. Keep up on all Covid related issues.

65. Assist in supervision to DSP and House Managers to insure compliance with safety standards, work ethics, and job performance.

66. Follow infection control precautions in all situations.

67. Give report to the Administrator.

68. Give report to DSP.

69. Follow HIPPAA privacy guidelines according to the following standards:

70. Workforce member is required to maintain the confidentiality of all protected health information whether electronic, written or oral to which he/she may be exposed either during the course of his/her duties or as the result of an incidental disclosure.

71. Workforce member will receive training regarding all aspects of his/her job duties that are affected by the HIPAA privacy rule.

72. Workforce member is required to apply the Minimum Necessary Standard in all matters related to patients' protected health information.

73. The duty of privacy protection continues during non-working hours and after workforce member is no longer associated with Covered Entity.

74. Perform other responsibility as assigned.

Qualifications:

1. Current Nursing License from the Illinois Department of Professional Regulation.
2. Experience is desirable but not mandatory.
3. Ability to supervise and administer nursing care and treatment is essential.
4. Possess characteristics of understanding, patience, and tact in dealing with clients, their families, and visitors.
5. Excellent oral and written communication skills.
6. Follows HIPPA and CIL guidelines in maintaining confidentiality of all Client information.
7. Support the CIL mission statement.

Physical Requirements:

1. Ability to communicate in English via phone, in writing and verbally in conversation with different levels of staff, client families, and any outside contacts.
2. The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
3. While performing the duties of this job, the employee is frequently required to stand and walk. The employee is occasionally required to sit; use hand or fingers, handle, or feel; reach with hands and arms; talk or hear; and taste or smell. The employee must occasionally lift and/or move up to pounds. Specific vision abilities required by this job include close vision, distant vision, peripheral vision, depth perceptions, and ability to adjust focus, ability to utilize a computer, phone. etc. for extended periods of time.
4. While performing the duties of this job, the employee is occasionally exposed to blood or body fluids, fumes or airborne particles and toxic or caustic chemical. The noise level in the work environment is usually moderate.
5. Lifts and carries light objects such as client charts etc. without assistance.
6. Occasionally transfers up to 75 pounds with assistance while lifting, positioning and transferring clients.
7. Stands, walks up to 75 percent of the shift to carry out responsibilities.
8. Stoops, bends, and squats as required to reach lower drawers in medication carts, file cabinets, etc.
9. Able to wear gloves and other protective equipment.
10. Possesses eye-hand coordination.
11. Possesses skills for continuous handling, fingering, and feeling required for client assessment and maintaining equipment.
12. Possesses necessary skills to continuously comprehend and communicate with clients and staff, to develop and follow written policies and procedures.