<ul> <li>Maintain annual HHRG values at the National Standard as appropriate. </li><li>Utilize HHRG values to establish visit frequency and to establish appropriate interdisciplinary utilization. </li><li>Annual outcomes meet National Benchmarks. </li><li>Refers to community resources as appropriate. </li><li>Evaluates the clinical needs of the patient; initiates, develops, implements and makes necessary revisions to the patient's plan of care; addresses all problems in the plan of care and documents accordingly. </li><li>Participates in inter-disciplinary patient case conferences; evaluates effectiveness of established plan of care. </li><li>Instructs and provides documented supervision of the Home Health Aide plan of care every 14 days. </li><li>Notifies MD/other involved care providers of significant changes in the patient's condition. </li><li>Completes admission and other paperwork on a timely basis. </li><li>Records narrative documentation to reflect skilled care. Documentation is clear, concise and addresses specifics of teaching, direct care and response of patient / caregiver. </li><li>Obtains and clarifies valid MD orders for all care delivered. </li><li>Plans and coordinates discharges appropriately and informs patient/MD and records disposition of patient in the discharge summary. Completes all appropriate discharge paperwork. </li><li>All other duties as assigned. </li><li>Successful passage of VNA pre-hire medication test </li><li>Current RN license in Mass. and other related credentials to meet specialty. </li><li>Minimum one (1) year of nursing experience required or 6 months of nursing experience with a BSN. </li><li>CPR certification required. </li><li>Home care and IV experience, computer skills and BSN preferred. </li></ul>