Job Summary: Provides age-appropriate skilled nursing care to patients in their place of residence in accordance with agency policy and procedure and state and federal regulations. Teaches the patient/family disease process and self-care needs. Monitors physiological state to determine an appropriate level of safety and comfort. Provides services requiring nursing skills in accordance with the plan of care. Develops and coordinates the plan of care and provides case management. Performs duties consistent with the nursing practice act that includes the standards of competent performance including Title 16, Chapter 14, Section 144.3 of the California Code of Regulations. Essential Responsibilities: • Provision of Care • 1. Provides the initial all system nursing assessment prior to the provision of care. • 2. Initiates the plan of care and necessary revisions including obtaining written physician orders for changes. • 3. Provides care and services in accordance with the plan of care. • 4. Performs assessment/data collection in an on-going systematic manner, focusing on physiologic, psychosocial, cultural, spiritual and cognitive status; also nutrition, pain, patient/family education, family involvement and patient advocacy. • 5. Provides ongoing periodic all system assessment of the patient and the patient’s equipment needs. • 6. Initiates preventative and rehabilitative nursing procedure (Home Health). • 7. Initiates timely discharges based on goals. • 8. Educates and instructs the patient, patient’s family or other staff as required. • 9. Counsels the patient and family in meeting nursing and related needs. • 10. Supervises and teaches LVN’s and HHA’s as required for patient care. • 11. Provides nursing care through all phases of care taking into consideration age and developmental needs. • Documentation and Communication • 1. Documents all care, interventions and care coordination per law, regulation and agency policy. • 2. Notifies the patient’s attending MD, Podiatrist and other professional persons and responsible staff of significant changes in the patient’s condition in a timely manner. • 3. Assists in coordinating all services provided. • 4. Consults with other health professionals when needed. • Planning, Organizing and Productivity • 1. Effectively plans and organizes work assignment, manages and sets competitive priorities, and completes work assignments with a minimum of direct supervision per agency policy and within established time frames. • 2. Adheres to the services policy and principles of the Kaiser Permanente Medical Care Program. • 3. Supervises Home Health aides and LVNs according to law, regulation and agency policy. • Professional Behavior • 1. Behaves in a courteous professional manner with patients, health professionals and maintain patient confidentiality. • 2. Acts as a patient advocate in utilizing Medicare, MediCal, Health Plan and community resources. • 3. Participates in Departmental Quality Assurance activities and Utilization Review activities as requested. • Self-Development • 1. Selects and attends education programs to keep current in area of practice. • 2. Utilizes new knowledge and skills. • 3. Participates in in-service programs. • 4. Annually prepares realistic professional goals and reviews their progress with Supervisor. • Perform other related duties as necessary. • Supervisory Responsibilities: • The job has no supervisory responsibilities.