Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Develops and implements appropriate plan of care (POC) that complies with referral source orders, specific treatment measures, frequency/expected duration and discharge goals in partnership with the patient, healthcare provider, patient representative (if any) and/or caregiver(s) based on thorough assessment incorporating all aspects of patient limitations and goals, and potential discharge environment. Documents accurate and ongoing assessment/reassessment, treatment and discharge of the patient: nursing interventions, patient response to care provided, patient/caregiver educational needs, problems, capabilities, limitations and progress toward goals. Documentation includes evidence of appropriate patient/caregiver teaching, and the understanding of these instructions in accordance with agency guidelines. Engages the patient /caregiver in meaningful education as indicated per care plan. Communicates with ordering provider and other health practitioners related to the current POC. Demonstrates responsibility to effectively coordinate the patient’s POC with members of the Interdisciplinary Team and other health professionals through team/patient care conference. Updates patient’s short-term/long-term goals as appropriate based on interdisciplinary team assessments and re-assessments. Participates in interdisciplinary team, agency projects, committees, QAPI program and/or other activities upon request and approval from direct supervisor. Attends Agency In-service programs. Safely operate a personal vehicle while traveling throughout Granite VNA service area to provide patient visits and/or attend meetings. Other Job Functions. Supervise Licensed Practical Nurses and Licensed Nursing Assistants assigned to patients according to federal and state regulations. Coach, mentor and precept new nursing team members and students. Performs job duties in a safe manner in order to prevent injury to yourself and others. Expected Hours of Work. The team member will be scheduled to work based on program and Agency needs. Work assignments include holiday, weekend and/or on-call rotation. Requirements Graduate of an accredited school of Nursing, accompanied by current New Hampshire nursing license, or compact state license through the Nurse Licensure Compact (NLC)One year of recent general medical/surgical or skilled/acute care nursing experience Valid driver's license, reliable transportation and an acceptable driving record.