Performs nursing assessments and develops, implements and evaluates plans of care in conjunction with the physician, patient and caregivers per agency policy and procedure Evaluates the effectiveness of the plan of care, the patient’s response to care and outcomes of care and revises the plan of care as needed Re-evaluates patient nursing needs to include on-going assessments using the OASIS data set at appropriate time points Provides skilled nursing services that require substantial and specialized nursing care including medication administration, wound care, therapeutic treatments, and skilled teaching as ordered and indicated Plans and implements patient health teaching and health counseling regarding the disease process(es), self-care techniques and prevention and involves the patient’s significant others in accomplishing health goals while promoting patient/family independence Participates in health promotion and disease prevention activities Initiates appropriate preventive and rehabilitative nursing procedures following the physician’s plan of care Coordinates services and scheduling with the Clinical Team Manager (CTM) and Clinical Team Coordinator (CTC) to include recommendations for additional home health care services for patients to within 24 hours of Start of Care (SOC) Assesses the patient's condition during every home health care visit; insures assessments are communicated to the Clinical Team Manager on a daily basis; nursing interventions are implemented to meet patient needs and changed conditions Performs care management duties on patients as assigned including: notifying the physician of changes in the patient’s condition or progress toward goals, obtaining needed physicians orders, reassessing the patient for recertification, supervision of LVNs and home health aides, attending and documenting case conferences, coordination of care by reporting of significant findings to others on the healthcare team, and planning for, notification of and documenting the discharge of the patient Documents all communications with the patient, family, physician, CTM, pharmacy, other disciplines, and appropriate others as indicated on communication notes Prepares a written plan for the Home Health Aide to follow, if applicable Expresses verbal and written communication in a clear, positive and cooperative manner  Additional Home Health Aide duties as needed