Nurse- Residential Services Program

Nurse- Residential Services Program

Responsible to Assess, Document, Communicate and Confirm Implementation of each Client's Medical Treatment PlanEnsure a system is in place to meet the physical health needs of all residents including, but not limited to, tirage services, provision of direct services, coordination of services, and communication with pertinent individuals. Assess resident's healthcare needs at time of admission and ongoing, contribute to the development of the physical health/medical domains of the residents' Individualized Service Plan (ISP), and monitor progress and implementation of the plan. Evaluate and adjust the plan as needed, keeping the residents' treatment team and leadership informed of progress and needed changes. Review and monitor IS{s and Behavior Intervention Plans (BIP) for medical contraindications. Have a working knowledge of the physical health aspects of the residents' care, including weight, nutrition, allergies, medication education, assessing and education of side effects, risks and benefits of medication. Manages medication and prescription acquisition, distribution, and administration. Follow up to ensure proper medication procedure is followed. Ensure medications are administered, as prescribed by the physician, and are documented accordingly. Conduct Quality Assurance reviews of prescribers discharge summaries, prescriptions, medication logs, etc. Create and Implement training to ensure staff are aware of relevant medical needs of residents. Provide ongoing training to staff in the safe handling of medication and monitoring of residents self-administration of medications as prescribed by physicians as needed. Ensure the program meets compliance standards for relevant regulating agencies. Assist with client examinations and procedures, as needed, and specifically at intake and upon return from an unauthorized leave of absence. May perform procedures such as dressing wounds, etc. May provide emergency care for clients, or refer to emergency medical care. Assist, as needed, with the development of safety plans of residents with behavioral or medical risks. Performs other duties as required including, but not limited to, attending team meetings, completing health assessments for behavioral therapy plans, and providing input to the ISP development, creating/implementing policies and procedures under the supervision of the program director. Assist with the proper safe storage and disposal of unused/expired medications. Maintain accurate and complete medical records in compliance with external contracting agencies expectations and requirements set forth by regulating and licensing bodies. Document within the organization's Electronic Mental Record (EMR) and maintain the medical section of the resident's binder. Ensure documentation is submitted prior to the end of the shift to ensure up-to-date record for the collaboration and provision of direct care services by residential staff. Advocate for Client Medical Health with Client Care Team, Outside Providers and Family Members Collaborate with the Director of Residential Services, primary care physician, psychiatrists, custodial agencies, pharmacists, clinicians, comprehensive case manager, both within and outside of the agency. Coordinate any healthcare needs with the client's care team, outside providers and agencies, and family members, as needed. Provide health and wellness education to residents and their families. Serve as an advocate on behalf of residents. Communicate with all members of the youth's service team by participating on monthly staffings, quarterly ISP reviews, specifically specifically providing professional input regarding healthcare needs and medical contraindications.