Position Title: Quality Assurance (RN)

Reports To: Partner, Partner Advisor

Primary Relationship: Partner Team

Date: September 2024

Schedule: 9:00 PM to 6:00 AM PHT

Responsibilities:

Provide Quality Review for EMR visit documentation for completeness and accuracy IAW regulatory compliance
Maintain ongoing communications with Director of Nursing and Compliance Supervisor, as required
Perform EMR training in-house for Skilled LVNs and RNs as needed and serve as dedicated EMR trainer
Initiate the plan of care and make necessary revisions
Prepare clinical and progress notes and summaries of care
Inform the physician and other personnel of changes in the client's condition and needs
Counsel the client and family in meeting nursing and related needs
Oversee the coordination of care related to client therapy services, statistics, reports and records for purposes of coordinating therapy services
Assist in the development of organizational goals
Develop, recommend and administer agency policies and procedures
Assess competency of clinical staff and ensure staff is assigned in a manner that promotes quality, continuity and safety of a client's care
Supervise, educate and coach other nursing personnel/ care-giving staff
Plan and implement in-service and training programs
Oversee the maintenance of client clinical records, statistics, reports and records for
Assure proper maintenance of clinical records in compliance with local, state and federal laws
Assure compliance with all local, state and federal laws regarding licensure and certification of organization personnel
Identify and participate in performance improvement activities
Stay informed about changes in the field of Nursing. Share information with appropriate organization personnel
Work with community emergency response organization and local public health departments, as needed
Assure the highest quality of care is provided and documented in accordance with the Plan of Care
Perform the initial and ongoing assessment of the patient
Help develop and implement the Hospital Plan of Care as prescribed by the physician and in conjunction with the other members of the Interdisciplinary Group
Responsible for the education of the patient, family or other caregivers in relation to needs identified on the Plan of Care, including, but not exclusive of, medication administration, dressing changes, oxygen administration, Hospital philosophy and care of the ill patient
Work closely with other members of the Interdisciplinary Group to provide all-inclusive physical, psychosocial, educational, emotional and spiritual services including bereavement support to the patient and family to achieve the highest quality of care
Maintain primary control and professional management of each patient and act as primary liaison between physician, patient/ family and Hospital team so as to be fully aware and abreast of all clinical issues, staffing and scheduling concerns
Report any change in the patient's condition to the Attending Physician
Maintain close contact with the patient's family and/or significant others to provide information, support, and continuity of care
Maintain an accurate and updated medical record, including all interdisciplinary notes, Plans of Care, initial and ongoing assessments and any other information pertinent to the care of the patient
Perform ongoing review and follow-up on assigned patient clinical records to assure
Practice infection control measures and standard precautions
Participate in the Hospital's Quality Assessment and Performance Improvement Program
Attend staff meetings
Perform other activities as assigned
Consistently promote company's core values
Complete required Agency or Hospital annual training

Qualifications:
Graduate of Bachelor's Degree in Nursing
Registered Nurse is a must
Minimum 5 years of clinical experience with at least half of that time working in home health, hospital or related health care organization.
Minimum 1-2 years of direct employee supervision
Demonstrated ability to supervise and direct staff
Possess exceptional nursing assessment skills
CPR Certification is a plus

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