Provides oversight of all patient care services and personnel. The oversight provided must include the following: making or assisting the scheduler with patient and personnel assignments, coordinating patient care, coordinating referrals, assuring that patient needs are continually assessed and assuring the development, implementation and updates of the individualized plan of care are including all physicians involved in the plan of care and integrating the orders.Performs initial and ongoing comprehensive assessments of the patient’s needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points.Supervises the nursing clinical staff engaged in direct delivery of home care services in the initial evaluation of patient’s needs, the written goal-oriented plan of care and the implementation of the physician’s plan of treatment.Coordinates the total plan of care with appropriate resources, conducting periodic reassessments of patient needs and revising the plan of care as needed.Ensures care provided is based on a continual assessment of the patient that addresses physical, psychosocial, environmental and safety factors, physician’s orders, relevant medical history, functional status and availability of caregiver.
