Job description
Job Summary:
Responsible for assessing, establishing, and delivering a plan of care with ongoing evaluation to the adult (18 years old and over) who is diagnosed with substance use disorders and who may also present with mental health disorders and other co-occurring disorders.
Essential Functions:
- Screens individuals for potential admission via the telephone (or walk-ins) to ensure the level of care is appropriate, based on Registered Nurse assessment, known as Initial Determination of Services, and the OASAS LOCADTR tool. Obtains necessary information regarding medical, psychiatric, trauma screening, and substance use disorder history.
- Appropriately refers individuals to other referral services if the person is not eligible for stabilization level of care or if there is no bed availability. Completes documentation of individual’s screened but not admitted, to include reason for non-admission and identification of other referral agency.
- Receives and processes individuals through the intake based on unit guidelines in conjunction with the interdisciplinary team so that all forms are completed in the electronic medical record, including but not limited to Intake Consents, Informed Consent, and other Standardized Evaluation Tools.
- Ensures that each person clearly understands orientation to unit, fire safety, confidentiality, alcohol, drug and tobacco free policies and proper adherence to infection control and hygiene standards.
- Collects concise, accurate health data information, completes the Health Screening form and documents the nursing initial assessment note. When necessary, requests medical records related to physical exam and wellness that may have been performed by another provider during prior 12-month period.
- Conducts TB Surveillance on all individuals, administers TB Mantoux test as indicated and provides TB education. Within 48 to 72 hours of PPD administration, provides assessment of test and documents accordingly in the record. Ensures PPD information is obtained from outside agencies as appropriate.
- Orders, receives and stores medication from pharmacy in accordance with policy. Supervises self- administration of the individual’s medication and provides medication education, as needed. Completes all documentation, including the Medication Self-Administration Record; obtains the individual’s signature/initials and documents that the person understands medication risks and benefits.
- Ability to follow medical and/or psychiatric practitioner orders, including but not limited to telephone orders.
- Observes and monitors individuals to determine signs and symptoms of withdrawal and other moods and behaviors. Provides and documents general nursing care. Facilitates transition to alternate level of care as appropriate.
- Ability to provide rescue care, including cardio-pulmonary resuscitation and application of Narcan, if necessary.
- Identifies and prioritizes physical and mental health concerns based on presenting problems and includes short-term nursing goals on the Health Screening Form.
- In conjunction with interdisciplinary team, ensures unit rounds are completed and documented accordingly on the Rounds Sheet.
- In conjunction with interdisciplinary team, enters medications (and count, as applicable) on the Discharge Plan in the electronic medical record, and if needed, obtains the individual’s signature on the Discharge Plan.
- Provides individual health education as needed and develops and facilitates educational health topics for group meetings.
- Ability to navigate electronic medical record, utilizes appropriate medical terminology, and proper spelling and grammar in documentation.
- Ability to review medical record chart to determine accurate charting standards.
- Reports any unit medication stock or supplies that need replenishment.
- Ensures all required in-services/trainings and certifications are up to date
- Interrupts and reports suspected abuse to Administrator immediately.
Education and Qualifications:
- Maintain current NYS Registered Nurse license.
- Bachelor’s degree preferred.
- A minimum of 1 year experience preferred with individuals diagnosed with substance use disorders, including but not limited to secondary mental health disorders and other co-occurring disorders.
- Maintain current CPR Certification and Narcan training.
- NYS driver’s license maintained within agency criteria preferred
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