The Start of Care registered nurse plans and organizes home health care services based on the OASIS assessment, history and physical and medication reconciliation, and the unique healthcare, communication, and learning needs of the patient and their caregiver and representatives. The Start of Care nurse builds from the resources of the community to plan and arrange services to meet the needs of individuals and families within their homes and communities.

Core Competencies

Adheres to infection prevention guidelines
Adheres to policies, procedures, and standards of practice to deliver safe and optimal care
Assesses patient history, physiological, and psychosocial status
Communicates with the patient, family, medical staff and others during the continuum of care
Complies with Joint Commission’s national patient safety goals
Complies with organizational quality dashboard/benchmarking goals
Interprets common variables affecting patient care and follows reporting process
Maintains regulatory compliance consistent with quality standards and ethical obligations of the profession
Participates in activities in alignment with the Magnet Model
Participates in organizational activities
Participates in Peer Review
Participates in professional development activities
Performs as a preceptor in an active and engaged manner
Provides age-specific individualized care that supports protection from harm and complies with patient safety centered interventions/bundles
Provides patient and family education throughout the care of patient
Uses critical thinking to formulate and carry out a care plan according to patient needs
Utilizes resources in an economical manner
Utilizes safe administration of medications
Utilizes Safe Patient Handling

Department Specific Competencies

Completes an initial assessment of patient and family/representative to determine home health care needs.
Conducts a complete physical assessment and history of current and previous illness(es).
Conducts an environmental assessment following The Joint Commission Standards to ensure the home is safe and appropriate for the delivery of care.
Completes the OASIS Assessment Tool and validates accuracy before submission to the Performance Improvement Coordinator.
Initiates the plan of care after discussion with the Primary Care Physician and Specialists managing the patient’s care.
Performs a comprehensive medication reconciliation with patient and family/representative and physicians involved in care
Uses health assessment data to determine nursing diagnosis and related goals and interventions.
Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions.
Includes the patient and the family/representative in the planning process.
Administers medications and treatments as prescribed by the physician.
Determines need for translation services or communication aides and arranges for the appropriate resources to meet these needs.
Completes the appropriate consents and regulatory notices after explaining home health specific patient rights and responsibilities in a manner appropriate to the patient, family/representative.
Explains the patient’s financial responsibility for the services proposed.
Provides written health care instructions to the patient, family/representative as appropriate per assessment and plan of care.
Identifies initial discharge planning needs as part of the care plan development.
Communicates with the physician(s) regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
Communicates with community health related persons to coordinate the care plan.
Participates in on-call duties as defined by the on-call policy.
Ensures that arrangements for equipment and supplies and other necessary items and services are completed and communicates to the assigned Case Manager or Team Manager.
Prepares initial home health aide care plan and provides instruction to the assigned CHHA.
Provides Start of Care report to Manager immediately following assessment to facilitate scheduling of Case Manager and other disciplines.
Completes and corrects all documentation within 24 hours.

Education
Degree	Program
College Diploma	Nursing
Additional Information
Completion of an OASIS C2 course with one year of hire

Experience
Number of Years Experience	Type of Experience
2	nursing
Additional Information
6 months in home health

License / Certification Requirements
Registered Nurse License
BCLS or ACLS Certification
Drivers license, auto insurance and reliable transportation
Compensation Range: $55.80 - 82.88 / Hour

Core Competencies

Department Specific Competencies

Education

Experience

License / Certification Requirements

Torrance Memorial Medical Center

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Start of Care RN III - Home Health FT Days