JOB SUMMARY A registered professional nurse is responsible for the diagnosis and treatment of human responses to actual or potential health problems through such services as case finding, health teaching, and health counseling; nurses provide interventions supportive to or restorative of life and well-being; and execute medical regimens prescribed by a physician, dentist or other licensed health care provider. ESSENTIAL JOB FUNCTIONS: List all essential job duties. (To perform this job successfully, an individual must be able to perform each essential duty listed satisfactorily with or without a reasonable accommodation. Reasonable accommodations may be made to enable qualified individuals with a disability to perform the essential duties unless this causes undue hardship to the agency.) To perform this job successfully, an individual must be able to perform each essential duty listed satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions unless this causes undue hardship to the agency. · Participates in the pre-admission evaluation study and plan; the evaluation study, program design and placement of the resident at the time of admission to the SUD’s clinic; the periodic reevaluation of the type, extent and quality of services and programming; and the development of discharge plans and referral to appropriate community resources · Based on a comprehensive review of the client's overall condition, prepares, continually reviews and evaluates plans of nursing intervention to ensure that such interventions are consistent with the client's comprehensive treatment plan. Ensures, plans of nursing intervention include consideration of the client's cultural and ethnic background, customs, needs, beliefs, and primary language. · Develop treatment plans, in conjunction with the Interdisciplinary Team, consisting of an evaluation of the nursing needed and selection of nursing procedures and practices, which will best serve the clients' health care needs. · Develops, nursing assessment to reflect holistic needs of each client with consideration of his/her psychological, physiological, social, ethnic, cultural, educational and spiritual strengths and needs. · Oversees the direct implementation of nursing care to ensure that it is carried out in accordance with the plan of nursing intervention, and overall treatment/service plan, and to ascertain if the needs of the client require modification of the plan. · Coordinates nursing care activities with other professional disciplines to ensure that the nursing plan is consistent with and integrated with the total treatment/service plan and SUD Assessments · Participates at team meetings and provides nursing input on the development and implementation of treatment/service plans. · Conduct in-service training with regard to personal hygiene, medication administration, family life and sex education. Supervise medication administration practicums and sign off on medication administration monthly. · Control communicable diseases and infections through: identification and assessment, reporting to medical authorities, and implementation of appropriate protective and preventive measures. · Record on the clients' medical records nursing observations and action taken, such as nursing care given, medications and treatments given, reactions to treatments, tests, the intake and output of fluids and solids and the resident's vital signs. Record nursing needs of clients. · Modify the nursing plan, in terms of the clients' daily needs, at least annually for adults in accordance with developmental and medical changes. · Be available for on-call duty. · Work with all consulting and/or contracted medical service providers to in-sure appropriateness of service & to insure that recommended treatments are appropriate and are carried out, integrated and documented into the treatment plan. · Ensure that the inventory standards for medicines, solutions, supplies and equipment are maintained to meet nursing care needs. · Account for the issuance of controlled drugs and narcotics and inventories of these drugs. · Ensures client protection from health hazards such as transmission of infectious organisms, isolation of infected clients and use of properly sterilized equipment when its use is necessary. · Provide appropriate information to the client and family about such areas as sustaining and preventive health care, personal hygiene, methods of family or self-treatments, self-medication and possible side effects of medications. · Serve as liaison, client's interpreter with outside health services providers and escort clients to services as needed. · Train designated staff, by way of demonstrations and written and oral instructions, in the performance of select nursing techniques and the use of nursing equipment, and client specific condition trainings. · Provides health education/teaching for clients and their families. · Participates in risk management and quality assurance concerning health related issues. · Provides emergency care and crisis intervention · Accesses medications and observes and records effects and side effects. · Participates in professional activities to improve personal skills and knowledge. · Provides Nurse Vacation coverage, phone availability during workday hours, and a minimum of one site visit at covering site, for Nurse Responsibility review and weekly reporting. · Integrated Services Nursing Triage Service - After Hours, Weekends, and Holiday’s (5pm – 9am) – On a pre-determined rotation, across all Division Nurses · Performs other related duties as assigned. Additional responsibilities of the Residential Nurse in the Integrated Division Consumer Medical Records-Maintain medical record of each individual and ensure all appointments occur as prescribed and on time · Schedule and coordinate all medical appointments in conjunction with Medical Specialist · Follow up on all Medical Doctor recommendations following every appointment · Ensure follow up on all medication changes, making sure the order has been sent to the pharmacy, Medication Administration Review has been updated, medication change log updates, bright colored posting of information has been placed and the information transcribed in the AMAP communication log · Conducting weekly medical meetings (to occur every Wednesday) · Review all consults and ensuring compliance with all recommendations · Ensure the updating of the Appointment Tracking Log as it is an Integrated Division System · Complete SUD Nurse Progress Note and filing all consults once the progress note has been written · Review and edit MARS Monthly upon delivery Medication- Responsible for Medication Administration without Error · Ensure all AMAP Certifications are current · Schedule and conduct all recertification pouring’s · Ensure all medication supplies of each consumer is present and labeled according to doctors’ orders · Ensure the consumer’s Medication Administration Review is updates according with all medication changes, neatly organized with formularies and doctor’s order attached · At least once per week, conduct a full 100% audit of all clients’ medication and document results on the Integrated Division Medication Regimen Review Checklist. Follow up on any discrepancies immediately. · Ensuring an adequate refill supply at all times by logging into refill alert and communicating with the pharmacy and medical doctor as necessary Medical Assessments · Annual, Semi, Quarterly, Self-medication assessment, 24-hour Nursing Care and Medicaid Certifications as needed Consumer Weights · Complete within the first 7 days of the month and follow up on any significant increases or decreases immediately Weekly Medical Reports- · To be disseminated at the end of each week to the team. Capturing a recap of all appointments from the week and all follow up recommendations. · Team members include: Manager, Assistant manager, QIDP, Medical Specialist, Senior Vice President, Director of Nursing, Director of Food and Nutrition and Consulting Dietician 6. Conduct trainings according to Part 822, SUD clinic regulations for staff and clients ESSENTIAL KNOWLEDGE, SKILLS AND ABILITIES · Knowledge of professional nursing concepts, principles and practices. · Knowledge of concepts and principles from the biological sciences that is supportive of nursing practice · Knowledge of concepts and principles of health promotion and disease prevention. · Knowledge of abnormal signs and symptoms relating to physical and mental illness, as well as indicators of wellness · Knowledge of medications and drugs, common dosages, their psychological, physical and physiological effects and possible adverse reactions. · Knowledge of emergency treatments and interventions. · Knowledge of teaching and consulting techniques. · Knowledge of the Agency's routines, procedures and policies. · Knowledge of cultural, ethnic, and linguistic needs of clients relating to cultural competence. · Ability to recognize changes in signs and symptoms that warrant the immediate action of a physician. · Ability to develop, evaluate, implement and modify a plan of nursing intervention to meet the needs of individual clients. · Ability to secure the cooperation of and work effectively with others. Ability to prepare accurate and timely reports. · Demonstrated commitment of the value of diversity, equity and inclusion. QUALIFICATIONS AND EXPERIENCE New York State License and current registration to practice as a registered professional nurse prefer at least one-year post RN licensure clinical nursing experience working with individuals with developmental/intellectual disabilities. #ICLRN
JOB SUMMARY A registered professional nurse is responsible for the diagnosis and treatment of human responses to actual or potential health problems through such services as case finding, health teaching, and health counseling; nurses provide interventions supportive to or restorative of life and well-being; and execute medical regimens prescribed by a physician, dentist or other licensed health care provider. ESSENTIAL JOB FUNCTIONS: List all essential job duties. (To perform this job successfully, an individual must be able to perform each essential duty listed satisfactorily with or without a reasonable accommodation. Reasonable accommodations may be made to enable qualified individuals with a disability to perform the essential duties unless this causes undue hardship to the agency.) 1. GENERAL TASKS (OVERVIEW) · Responsible for the overall safety, health, and welfare of all residents served. · Documents appropriately in H&H electronic medical records (EPIC) on residents served. Documentation should include health assessment, goal planning, health notes and any changes or recommendations in the resident health status and Warm hand off notes for patient moving to another program. · Conduct discharge note In EPIC for residents leaving the program · Complete the DHS Institutional Referral Form and Reasonable accommodation form if needed. · Communicate and document feedback from outside affiliate on incoming and current patient · Attends Weekly meeting with ICL and H&H · Must be available via phone for staff when not in office · Document and assess vital signs parameters of high-risk patients weekly or as needed and recognize when to call 911. · Must be able to triage to appropriate service and level of care between onsite care and tele health services. · Provide ongoing medication monitoring training and refresher for direct support staff. · Provides feedback on medical assessment to determine appropriateness for admission and discharge from the medical respite. · Responsible for medication cart review · Provide feedback on review of the medication administration record (MAR) · Ensure that the control substance count sheet is correct and confirm that there is a signature on the count verification sheet for each shift. · Provide patient education to residents regarding their treatments, medications and dietary needs in order to improve their health outcomes. · Ensures that clinical policies, procedures and standards of care are being followed. · Assist in completing consultation form for resident with medical/psychiatric and specialty appointments · Must be able to effectively respond to off hour’s resident’s needs that may arise at the Medical Respite. · Assist in performing minor first aid and wound care if needed · Responsible for infection control / blood borne pathogens standards and compliance using universal and standard precautions. · Review medication refrigeration/freezer log · Serves as a liaison with pharmacies as well as all consulting healthcare practitioners and medical offices. Ensure start of care plan is in place for new clients if needed · Provide weekly clinical notes to the team leader if needed · Attends weekly/monthly housing, assessment, staff meetings and supervision. · Anticipates, analyzes, diagnoses, and resolves problems. · Demonstrates initiative to learn and implement new concepts, technologies, and/or methods. · Demonstrate critical thinking, assessment, and problem-solving skills. · Demonstrate excellent interpersonal skills. · Works collaboratively and productively with others. · Demonstrate the ability to use Microsoft Office applications including, but not limited to Outlook, Excel and EPIC care link. · Performs other incidental and related duties as required and assigned. · Provides crisis intervention · Gives lecture and participates in community activities as a medical and mental health advocate. · Provides information and conduct lectures and discussion on various health topics, such as: the effect and side effect of medications, well-being, coping skills, dealing with anxiety, anger etc. KNOWLEDGE, SKILLS AND ABILITIES 1. Knowledge of professional nursing concepts, principles and practices. 2. Knowledge of concepts and principles from the biological sciences that are supportive of nursing practice 3. Knowledge of concepts and principles of health promotion and disease prevention. 4. Knowledge of abnormal signs and symptoms relating to physical and mental illness, as well as indicators of wellness 5. Knowledge of medications and drugs, common dosages, their psychological, physical and physiological effects and possible adverse reactions. 6. Knowledge of emergency treatments and interventions. 7. Knowledge of teaching and consulting techniques. 8. Knowledge of the Agency's routines, procedures and policies. 9. Knowledge of cultural, ethnic, and linguistic needs of clients relating to cultural competence. 10. Ability to recognize changes in signs and symptoms that warrant the immediate action of a physician. 11. Ability to develop, evaluate, implement and modify a plan of nursing intervention to meet the needs of individual clients. 12. Ability to secure the cooperation of and work effectively with others. Ability to prepare accurate and timely reports. MINIMUM QUALIFICATIONS AND EXPERIENCE License and current registration to practice as a registered professional nurse in New York State; prefer at least one year post RN licensure clinical nursing experience working with individuals with mental disabilities. #ICLRN
Essential Job Functions Participates in the pre-admission evaluation study and plan; the evaluation study, program design and placement of the resident at the time of admission to the residence; the periodic reevaluation of the type, extent and quality of services and programming; and the development of discharge plans and referral to appropriate community resources Based on a comprehensive review of the client's overall condition, prepares, continually reviews and evaluates plans of nursing intervention to ensure that such interventions are consistent with the client's comprehensive treatment plan. Ensures, plans of nursing intervention include consideration of the client's cultural and ethnic background, customs, needs, beliefs, and primary language. Develop treatment plans, in conjunction with the Interdisciplinary Team, consisting of an evaluation of the nursing needed and selection of nursing procedures and practices which will best serve the residents' health care needs. Develops, nursing assessment to reflect holistic needs of each client with consideration of his/her psychological, physiological, social, ethnic, cultural, educational and spiritual strengths and needs. Oversees the direct implementation of nursing care to ensure that it is carried out in accordance with the plan of nursing intervention, and overall treatment/service plan, and to ascertain if the needs of the client require modification of the plan. Coordinates nursing care activities with other professional disciplines to ensure that the nursing plan is consistent with and integrated with the total treatment/service plan Participates at team meetings and provides nursing input on the development and implementation of treatment/service plans. Conduct in-service training with regard to personal hygiene, medication administration, family life and sex education. Supervise medication administration practicums and sign off on medication administration monthly. Control communicable diseases and infections through: identification and assessment, reporting to medical authorities, and implementation of appropriate protective and preventive measures. Record on the residents' medical records nursing observations and action taken, such as nursing care given, medications and treatments given, reactions to treatments, tests, the intake and output of fluids and solids and the resident's vital signs. Record nursing needs of residents. Modify the nursing plan, in terms of the residents' daily needs, at least annually for adults in accordance with developmental and medical changes. Be available for on-call duty and to work varied shifts as the need arises. Work with all consulting and/or contracted medical service providers to in-sure appropriateness of service & to insure that recommended treatments are appropriate and are carried out, integrated and documented into the treatment plan. Ensure that the inventory standards for medicines, solutions, supplies and equipment are maintained to meet nursing care needs. Account for the issuance of controlled drugs and narcotics and inventories of these drugs. Ensures resident protection from health hazards such as transmission of infectious organisms, isolation of infected residents and use of properly sterilized equipment when its use is necessary. Provide appropriate information to the resident and family about such areas as sustaining and preventive health care, personal hygiene, methods of family or self-treatments, self-medication and possible side effects of medications. Serve as liaison, resident's interpreter with outside health services providers and escort residents to services as needed. Train designated staff, by way of demonstrations and written and oral instructions, in the performance of select nursing techniques and the use of nursing equipment, and client specific condition trainings. Provides health education/teaching for clients and their families. Participates in risk management and quality assurance concerning health related issues. Provides emergency care and crisis intervention Accesses medications and observes and records effects and side effects. Participates in professional activities to improve personal skills and knowledge. Provides Nurse Vacation coverage, phone availability during workday hours, and a minimum of one site visit at covering site, for Nurse Responsibility review and weekly reporting. IDD Division Nursing Triage Service - After Hours, Weekends, and Holiday’s (5pm – 9am) – On a pre-determined rotation, across all IDD Nurses Performs other related duties as assigned. Additional responsibilities of the Residential Nurse in the IDD Division Consumer Medical Records-Maintain medical record of each individual and ensure all appointments occur as prescribed and on time Schedule and coordinate all medical appointments in conjunction with Medical Specialist Follow up on all Medical Doctor recommendations following every appointment Ensure follow up on all medication changes, making sure the order has been sent to the pharmacy, Medication Administration Review has been updated, medication change log updates, bright colored posting of information has been placed and the information transcribed in the AMAP communication log Conducting weekly medical meetings( to occur every Wednesday) Review all consults and ensuring compliance with all recommendations Ensure the updating of the Appointment Tracking Log as it is a IDD Division System Complete Residential Nurse Progress Note and filing all consults once the progress note has been written Review and edit MARS Monthly upon delivery Medication- Responsible for Medication Administration without Error Ensure all AMAP Certifications are current Schedule and conduct all recertification pouring’s Ensure all medication supplies of each consumer is present and labeled according to doctors’ orders Ensure the consumer’s Medication Administration Review is updates according with all medication changes, neatly organized with formularies and doctor’s order attached At least once per week, conduct a full 100% audit of all consumers’ medication and document results on the IDD Division Medication Regimen Review Checklist. Follow up on any discrepancies immediately. Ensuring an adequate refill supply at all times by logging into refill alert and communicating with the pharmacy and medical doctor as necessary Medical Assessments Annual, Semi, Quarterly, Self-medication assessment, 24 hour Nursing Care and Medicaid Certifications as needed Consumer Weights Complete within the first 7 days of the month and follow up on any significant increases or decreases immediately Bowel Movement Ensure Consumers bowel movement are charted consistently and implementing prescribed protocol should any discrepancies be noted Weekly Medical Reports- To be disseminated at the end of each week to the team. Capturing a recap of all appointments from the week and all follow up recommendations. Team members include: Manager, Assistant manager, QIDP, Medical Specialist, Senior Vice President, Area Director, Director of Nursing, Behavior Intervention Specialist, Director of Food and Nutrition and Consulting Dietician Staff Training Conducting AMAP refreshers at least quarterly and other in-services of consumer protocols as needed. Essential Knowledge, Skills and Abilities Knowledge of professional nursing concepts, principles and practices. Knowledge of concepts and principles from the biological sciences that is supportive of nursing practice Knowledge of concepts and principles of health promotion and disease prevention. Knowledge of abnormal signs and symptoms relating to physical and mental illness, as well as indicators of wellness Knowledge of medications and drugs, common dosages, their psychological, physical and physiological effects and possible adverse reactions. Knowledge of emergency treatments and interventions. Knowledge of teaching and consulting techniques. Knowledge of the Agency's routines, procedures and policies. Knowledge of cultural, ethnic, and linguistic needs of clients relating to cultural competence. Ability to recognize changes in signs and symptoms that warrant the immediate action of a physician. Ability to develop, evaluate, implement and modify a plan of nursing intervention to meet the needs of individual clients. Ability to secure the cooperation of and work effectively with others. Ability to prepare accurate and timely reports. Qualifications and Experience New York State License and current registration to practice as a registered professional nurse, prefer at least one year post RN licensure clinical nursing experience working with individuals with developmental/intellectual disabilities. #ICLOTHER
Under the supervision of the Registered Nurse and Program Director, and as a member of an inter-disciplinary treatment team, assumes case management responsibilities for assigned caseload of individuals who have mental illness and substance abuse disorder. Renders nursing care as assigned by registered nurse in accordance with recognized nursing techniques, procedures and established standards based on the scope of practical nursing. THIS IS A FIELD OPPORTUNITY ESSENTIAL TASKS: Assumes case management responsibility of assigned caseload of individuals. Assertive engagement and provision of mental health services in the community where consumer lives- up to 80% of weekly work schedule may involve field work. Continuous responsibility (24/7) for individuals engaged in the CB ACT or BUCSC ACT program. Assists individuals in assigned caseload to see the relationship between their substance abuse and their problems in living, the process of motivating the client to accept abstinence-oriented treatment. Crisis assessment and intervention. Symptom assessment, management, and supportive counseling Assist consumers to obtain the basic necessities of life. Provide assistance to consumers in structuring and performing basic daily activities. Assists consumer in the development and support of social activities and relationships. Assists consumer in accessing substance abuse treatment. Acts as liaison to the Criminal Justice system on behalf of consumer. Provides support to the program participants’ families and significant others. Provides intensive housing supports. Maintains accurate and timely case records, including but not limited to: weekly progress notes, quarterly service plan reviews, assessments and medical records. Provides and/or arranges for emergency medical care. Assesses consumers’ health condition on a daily basis. Effectively communicates consumers’ changing needs and plan of care among team members. Reports consumer needs, problems, and observations regarding consumer’s health to the registered nurse and/or physician. Assist in the formulation of a nursing diagnosis and treatment plan recommendations, including short-term and long-term goals as part of an inter-disciplinary team. Records observations and actions. Conducts or assists other team members in providing informational and educational discussions and materials with consumers on topics such as: the effects of medication, coping skills, assertiveness training, sexuality, etc. May conduct basic first aid training for consumers. Provides information concerning health referrals to consumers such as: health resources in the community, etc. Participates in staff development activities and programs Maintains current first aid and CPR certification. Perform other related job duties as assigned. ESSENTIAL KNOWLEDGE, SKILLS AND ABILITIES: Ability to work with consumers/residents, families, and staff in a caring and respectful manner, and with due understanding of and consideration for cultural differences. Ability to serve as a role model to residents/consumers, including modeling appropriate interpersonal interactions, demeanor, etc. Ability to effectively use required software such as IMA, Word, Outlook, and other technology required by ICL. Basic understanding of the causes and processes of mental illness and substance abuse disorder. Willingness to continually learn and apply knowledge and willingness to participate in in-service training and development activities. Ability to function as an effective team member, including performing share of work, cooperating with coworkers, and securing cooperation, and maintaining professional relationships and boundaries with co-workers, supervisors and consumers. Ability to use sound judgment in identifying and solving problems, and knowing when to seek assistance. Ability to be aware of self and one’s impact on others Ability to learn, understand and comply with all regulations, policies and procedures. Ability to organize time effectively to accomplish all tasks in a timely way and meet deadlines without prompting. Ability to develop, evaluate, implement and modify a case management plan, meeting all deadlines and productivity standards Ability to communicate effectively with staff, consumers/residents, families, and the public both orally and in writing. Ability to prepare accurate and timely documentation, reports and other written material as assigned. Ability to work independently, and to conform to all applicable safety and accountability measures Ability to be empathic, actively looking for ways to help people, to be compassionate and hopeful and to believe and help others work toward recovery. Ability to engage in active listening—attending to what other people are saying and asking questions as appropriate Ability to report for work as scheduled on a consistent basis Ability to be ethical- to understand and adhere to internal and external laws, rules, and policies MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS: Education: Must possess valid NYS license as Licensed Practical Nurse and current NYS registration, plus at least one year of experience providing services to individuals with serious mental illness. #ICLRN
