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Home Health Registered Nurse (RN)

Home Care for the 21st Century - South Houston
Sugar Land, TX
  • Posted: over a month ago
  • Full-Time
Job Description

The Registered Nurse is to provide nursing care, in accordance with the patient's plan of care, to include comprehensive health and psychosocial evaluation, monitoring of the patient’s condition, health promotion and prevention coordination of services, teaching and training activities, and direct nursing care.


  1. Coordinate total patient care by conducting comprehensive health and psychosocial evaluation, monitoring the patient's condition, promoting sound preventive practices, coordinating services, and teaching and training activities.
  2. Evaluate the effectiveness of nursing service, to the patient and family, on an ongoing basis.
  3. Perform admission, transfer, re-certification, resumption of care, and discharge OASIS for the home care patient.
  4. Prepare, and present, patient's record to the Clinical Record Review Committee, as indicated.
  5. Consult with the attending physician, concerning alterations of Patient Care Plans, checks with the appropriate supervisor, and makes changes, as appropriate.
  6. Coordinate patient services.
  7. Submit clinical notes, no less often than weekly, and progress notes and other clinical record forms, outlining the services rendered, as indicated.
  8. Submit a tally of patient care visits made each day.
  9. Participate in case conferences, discuss with the supervisor problems concerning the patients, and how they may best be handled.
  10. Discuss, with the appropriate supervisor, the need for the involvement of other members of the health team, such as the Home Health Aide, the Physical Therapist, the Speech Therapist, the Occupational Therapist, The Medical Social Worker, etc.
  11. Obtain orders for paraprofessional service and submit a referral to the appropriate personnel.
  12. Participate in the patient’s discharge planning process.
  13. Cooperate with other agencies providing nursing, or related, services to provide continuity of care and to implement a comprehensive care plan.
  14. Participate in staff development meeting.
  15. Continually strive to improve his/her nursing care skills by attending in-service education, through formal education, attendance at workshops, conferences, active participation in professional and related organizations, and individual research and reading.
  16. Participate in the development, and periodic revision, of the physician's Plan of Treatment and processes change orders, as needed.
  17. Maintain an on-going knowledge of current drug therapy.
  18. Adhere to federal, state, and accreditation requirements, including Medicare and Medicaid regulations.
  19. May be requested, by Clinical Manager, to fill in for the other nurses.
  20. Coordinates the admission of a patient to the Agency:
    1. Conduct an initial, and ongoing, comprehensive assessment of the patient’s needs, including Outcome and Assessment Information Set (OASIS) assessments, at appropriate time points.
    2. Obtain a medical history from the patient, and/or a family member, particularly, as it relates to the present condition.
    3. Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet, etc.
    4. Evaluate the patient, family member(s), and home situation, to determine what health teaching will be required.
    5. Evaluate the patient's environment to determine what assistance will be available, from family members, in caring for the patient.
    6. Evaluate the patient's condition, and home situation, to determine if the services of a Home Health Aide will be required and the frequency of this service.
    7. Explain nursing, and other Agency services to patients and families, as a part of planning for care.
    8. Develop, and implement, the nursing care plan.
  21. Provides skilled nursing care as outlined in the nursing care plan:
    1. Nursing services, treatments, and preventative procedures, requiring substantial specialized skill and ordered, by the physician.
    2. The initiation of preventative and rehabilitative nursing procedures, as appropriate, for the patient's care and safety.
    3. Observing signs, and symptoms, and reporting to the physician: reactions to treatments, including drugs, as well as changes in the patient's physical, or emotional, condition.
    4. Teaching, supervising, and counseling the patient, and caregivers, regarding the nursing care needs and other related problems of the patient, at home.
  22. Assumes responsibility for the care given by CNA/HHA
    1. Prepare the care plan for the Home Health Aide.
    2. Supervise, and evaluate, the care given by the Home Health Aide, as needed, and per Agency policy.
    3. Submit, to the appropriate department/individual, written evaluations of the Home Health Aides who are providing service to the patients, in his/her geographical area.
    4. Participate in periodic conferences, with the Home Health Aide supervisor, concerning the Aide's performance.
  23. Chart those services rendered to the patient, by the staff nurse, and changes that have been noted, in the patient's condition and/or family and home situation, makes revisions in the nursing care plan, as needed, records supervisory visits conducted with the Home Health Aide, evaluates patient care and progress, and closes charts of discharged patients.
  24. Provide guidance, and supervision, to the LPN and supervises the LPN, per Agency policy.
  25. Participate in the educational experiences for student nurses.
  26. Participate in the planning, operation, and evaluation of the nursing service.


  1. Must be a graduate from an accredited School of Nursing.
  2. Must hold an active license in the state, as a Registered Nurse.
  3. One, or more, years of experience, in community/home health agency setting, is preferred.
  4. Must have knowledge of Medicare and Medicaid guidelines.
  5. Must have a working knowledge of home healthcare, and the principles and techniques of professional nursing, and required documentation that pertains to it.
  6. Should be skillful in organization, and in the principles of time management, and have knowledge of management processes.
  7. Must be able to contribute to the quality of care being rendered, through constructive communication with nursing managers and staff.
  8. Must have a criminal background check.
  9. Must have a current CPR certification. Online certification is not accepted.

Environment, Physical Demands, and Dress Code


Contact with clients under a wide variety of circumstances. Care is provided in client’s living environment with varying situations, including private homes, independent or assisted living or in an institution such as a hospital or long-term care facility. May be required to respond to emergency situations. Travel required. Position includes tasks that have the potential for exposure to blood/body fluids/tissues and other potentially infectious material such as body fluids/tissues.

Physical Requirements:

Must be able to stand, walk, squat, bend, kneel, reach, twist, push and pull. Must be able to lift up to 50 lbs. Corrected visual and hearing acuity required.

Dress Code:

Scrubs and/or lab coat with Home Care for the 21st Century name badge unless specified by client.

Position Reports to the Clinical Manager

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Home Care for the 21st Century - South Houston


Sugar Land, TX
77478 USA



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