A clinical staff member who, in addition to performing routine team duties, has lead responsibility for evaluating the needs of assigned consumers for treatment; supervises and renders general nursing care (e.g., administers injections and medications) on an on-going basis. Provide psychiatric and medical assessment and treatment; and development, maintenance, and supervision of medication and psychiatric treatment.
Essential Accountabilities:
- Assist the prescriber on the team with assessment of client physical health, making appropriate referrals to community physicians for further assessment and treatment, and coordinating medical treatments with psychiatric treatment.
- Complete nursing assessment within 30 days of admission and yearly thereafter.
- Collaborate with the treatment team in comprehensive assessment of psychiatric history, mental status, and diagnosis; physical and dental health; use of drugs or alcohol; education and employment; social development and functioning; activities of daily living and family structure and relationships.
- Perform individual, group and family supportive therapy and illness education in the process of carrying out the tasks above.
- Transcribes the prescriber’s medication orders; administers prescribed injections and medications as needed. Observes consumer, records significant conditions and reactions, and notifies current prescriber of consumer’s condition and reaction to drugs, treatments, and significant incidents.
- Monitor and draw labs for clients as needed.
- Instructs consumers about daily medications (e.g., names of drugs, dosages, interactions, benefits). Reviews medication record of each consumer for potential adverse reactions, allergies, interactions, and contraindications on a monthly basis.
- Advise the prescriber of any medication errors and suggests changes.
- Records vital statistics and other pertinent data on consumers; maintains records of same.
- Maintains the medication administration record on a daily basis.
- Takes temperature, blood pressure, pulse, weight, and other vital signs to detect deviations from normal and determine progress of consumers.
- Liaisons with physician, dietitians, hospitals, pharmacies, and the consumer’s family on all health situations.
- Utilize the agency vehicle to conduct visits, escort consumers to appointments, transport food or goods for the consumers home or program sponsored activity.
- Responsible for input into CAIRS upon admission, bi-annually and discharge.
- Act as a clinical liaison between the team and outside entities.
- Document any progress notes in EHR within 48 hours of all client and collateral contacts.
- Ensure all documentation is completed in a timely fashion and remain in compliance with agency, OMH, and AOT regulations.
- Develop treatment plans with the input of other members of the ACT team and the consumers, if applicable.
- Coordinate services with other specialist on the ACT Team, i.e. Family specialist, Employment specialist, Substance abuse specialist, Case manager.
- Provides networking and linkages between the programs, mental health providers, requires both telephone and face-to-face contact;
- Attend and participate in all team meetings.
- Responsible for input into CAIRS upon admission, bi-annually and discharge.
- Act as a clinical liaison between the team and outside entities.
- Document any progress notes in EHR within 48 hours of all client and collateral contacts.
- Ensure all documentation is completed in a timely fashion and remain in compliance with agency, OMH, and AOT regulations.
- Assists in the planning, developing and implementation of goals and training to further develop participants’ skills, including but not limited to:
- Budgeting
- Grooming
- Nutritional planning
- Use of public transportation
- Use of community resources
- Shopping
- Housekeeping
- Physical health & development
- Adaptive behavior/independent living
- Nutrition
- Vocational development
- Social development
- Acts as a role model for participants; furthers participants in researching and obtaining community resources appropriate and applicable to their needs and goals; follows-up on any aftercare/recommendations for treatment. Escorts/ accompanies participant as needed on appointments (medical, psychiatric, substance abuse).
- Provide crisis intervention and mental health counseling as needed.
Input all visits and data into Vellohealth software.
Other Responsibilities:
- Demonstrate ability to: maintain required written documentations; communicate relevant information to other staff and supervisor(s), verbally and in writing.
- Ability to work flexible schedules as work schedules, trainings and location are subject to change
- Ability to operate an agency vehicle.
- Attend all required training’s and any relevant to the position or deemed necessary by Team Leader.
- Participate in activities of other staff members in their absence or during periods of staff shortage.
- Maintain confidentiality at all times.
- This does not limit the assignment of duties or exclude the performance of other duties not mentioned as assigned by supervisor, the Team Leader, Deputy Director, Director, and/or Senior Management.
- Responsible for reporting and documenting all incidents to immediate supervisor within 24 hours.
- Provide 24-hour/seven day a week emergency coverage via emergency cell phone to provide crisis intervention services after program hours on a rotating basis.
