The Program Nurse Provides normalized, therapeutic and preventative nursing care to individuals in the CLA programs at Brian’s House Incorporated (BHI) within the scope of the Pennsylvania Professional Nurse Act and in accordance with licensing, OSHA, Confidentiality and Brian’s House Incorporated policies and procedures. Position requires that the nurse assess the need for nursing intervention and develop health management needs for individuals. Also included is the responsibility to train individuals and staff to implement health care interventions as well as work with the interdisciplinary team to ensure optimum quality care is delivered.
Duties and Responsibilities:
Individual Health
- Perform assessments of clients’ health status on admission/discharge as well as on an ongoing basis when medical needs indicate and make decisions and/or recommendations for external medical attention contingent upon the circumstance which is then supported by supported documentation.
- Communicate and coordinate health information between Brian’s House Inc. Program Nurses, Program Directors and direct care staff, outside provider agencies, BHE Program Director, Medical Coordinator and other health professionals, routinely and whenever further assessment, evaluation or monitoring is required.
- Screening and triaging of individuals for illness/injury and determine the need for the implementation of routine, urgent and emergency care as identified in the BHI Nursing Policy and Procedure Manual.
- Individual case management of assigned individuals which includes coordinating, managing and monitoring psychiatric/medical/dental care and follow up. Assuring that medical/dental appointments are scheduled and necessary information accompanies the individual to the appointment and physician’s orders are implemented.
- Management of routine health care needs to include encouragement, implementation and promotion of health maintenance and injury prevention. All issues should be reported to the assigned Brian’s House Residential Program Director or designee and Medical Coordinator or designee.
- Development and maintenance of health management plans, records, lifetime medical histories and medication regimes for each individual.
Medication Administration
- Prepare and administer medications, treatments and tasks as ordered and in accordance with the BHI Nurse’s Policy and Procedure Manual.
- Evaluate therapeutic effectiveness of medication with pertinent data and report any observed side effects or relevant laboratory values to physician.
- Monitor and oversee all aspects of daily medication administration/issues for individuals to ensure accurate administration, documentation and storage.
- Review monthly medication sheets, clarify need for corrections, make corrections as necessary as well as communicate changes to direct care staff, Brian’s House Enterprises Nurse, Residential Program Director and Medical Coordinator.
- Ensure compliance with Brian’s House Incorporated Nursing Policy and Procedure Manual when obtaining, transcribing, checking, administering and storing medications; to include medication orders.
Communication
- Communication and coordination of pertinent health concerns or information on a routine basis with the Residential Program Director, House Supervisor and Medical Coordinator, staff, Program and BHE Nurses.
- Communication and collaboration with families/guardians, health care providers & BHI Program Nurses and Program Directors.
- Attendance at routinely scheduled Nursing Meetings as well as Program Director and Nurses Meetings and any in-service meetings in which specific health care concerns, management, needs, precautions/limitations and health issues for identified individuals are discussed.
- All communication is in accordance with BHI Nursing Policy and Procedure Manual for sections which include Observing and Reporting, Urgent, Emergency and Routine Care.
Records and Documentation
- See expectations of Charting in BHI Nursing Policy and Procedure Manual.
- Telephone communication is documented on an organizational Call Log.
- Document all relevant information (assessment, reporting, communication etc.) according to BHI Nursing Policy and Procedure Manual as identified on Medication Administration Record (front and reverse), Nurse’s Note, Nurse’s Tickler File, On Call Nursing Report and on all agency appropriate forms (such as Body chart or Incident Report) and graphs.
- Document assessment, intervention, and effect as well as follow up, to include communication in the nursing notes and other designated documentation locations as specified in the BHI Nursing Policy and Procedure Manual.
- Ensure and prepare documentation of physicals including health management orders and PRNs in addition to immunization forms and records.
- Maintain accurate regulatory and corporate medical information required for each individual which includes but is not limited to immunizations, Dental, Vision, Audio, Physicals, Medication, treatment and procedural orders (g-tube feedings, catheterizations etc.).
- Maintain accurate record keeping and determine that all concerns have been documented and follow through has occurred and been documented.
- Monitor physician’s orders to assure adherence to health care protocol and continue to monitor for follow up health care needs.
- Review all medical records for regulatory compliance, orders, intervention, follow up and accuracy.
- Submit monthly Program Memos to assigned Program Directors, Medical Coordinator and House Supervisors.
- Communicate with individual’s health care providers to assure that the correct health plan occurs and document accordingly. Monitor physician’s orders to assure adherence to health care protocol and provide feedback and supervision of health care needs.
Training
- Conduct organizational trainings which include but are not limited to the Medication Administration Course, Nutrition, Communicable Disease, Infection Control and Seizure Trainings.
- Conduct individual specific trainings which include but are not limited to the application/instillation of non-oral medications, glucometer, blood pressure and other health related trainings.
- Identify health concerns of individuals and provide in servicing as indicated.
- Ensure documentation of any residential or employee health related training.
Tasks
- Attend annual physical appointments, pertinent health appointments and ISP meetings.
On call rotation.
- Conduct site visits every 60 days, which includes inventory of supplies and ensuring that all supplies are available on-site for the delivery of care and equipment is functioning properly and clean.
- Compose Lifetime Medical Histories for individuals and update them annually.
- Administration in the development of quality assurance assessment procedures that will assure staff’s compliance to standards for quality health care and safety.
- Identify staff training needs as they relate to health and safety. Identify in services for clients/staff regarding health related issues and preventative health maintenance and report to Residential Program Director or designee and Medical Coordinator or designee.
- Staff nurse duties which includes primary care.
- Continually, monitor/evaluate BHI employees, procedures and conditions for health and safety. Communicate modifications that would create a healthier or safer program environment and report to Residential Program Director or designee and Medical Coordinator or designee.
Supervising
- At all times will provide staff supervision of health and safety related issues.
- Assist in the orientation of new nursing employees.
- Will complete other duties as determined by Medical Coordinator and Chief Executive Officer.
Continuing Education
- Participates in continuing education relevant to the area of nursing. Obtain a minimum of 24 hours of in-service training annually.
- Attain 30 continuing education hours every 2 years to maintain RN license.
EEOC
