Skilled Nursing Services Included in the Home Care Service Plan

  • RN Provides initial and ongoing assessments
  • RN Provides a skilled observation and assessment within 24 hours of admission
  • Resident specific care plan created based on individual needs and RN assessment
  • RN on call 24 hours per day
  • RN on site 5-plus days per week
  • RN care coordination with physicians, hospice care and other medical professionals
  • RN maintenance of clinical record information
  • RN coordination of laboratory and physician requests
  • RN closely reviews behavioral expressions
  • RN initiation of interdisciplinary care conference per guidelines
  • CNA and /or HHA on site 24 hours per day
  • RN provides CNA/HHA supervisory visit within 14 days of admission and intervals no greater than 62 days or more frequent if indicated by a clinical assessment
  • Staff trained in dementia care upon hire and with ongoing, continuous learning
  • Medication setup and central storage
  • Medication management with admission
  • Weekly and as needed vital sign checks
  • Weekly weight monitoring
  • 1:3 care ratios days and evenings 24 hour assistance with bathing, dressing and toileting
  • Incontinence management
  • Bowel and bladder monitoring
  • Daily skin care and monitoring
  • Cueing and redirection as needed
  • Monitoring of food and fluid intake
  • Coumadin management
  • Diabetes management, including insulin injections
  • Oxygen and/or Nebulizer Management
  • Catheter Care
  • Direct care staff trained in basic infection control
  • 1:1 feeding assistance
  • 2 person transfers during day and evening hours
  • End of life comfort care including: close supervision, proper timing of medication depending on symptoms and bed bound cares
  • Complete housekeeping services for suite and all common areas
  • Personal laundry and linen service
Additional Medical Supplies: Responsible party is responsible for payment of additional medical supplies approved necessary by an RN for continued well-being of resident, such as but not limited to: nutritional supplements, wound care supplies, fall prevention individual monitors/alarms and pull-up incontinence supplies.