Provides direct patient care, evaluates outcomes and adjusts nursing care process as indicated to ensure optimal patient care. Initiates, coordinates and evaluates patient and family centered health teaching. Establishes the plan of care in collaboration with the physician, patient and UM Professional in accordance with the physician orders and patient needs. Advises and consults with family and other agency personnel, as appropriate. Completes documentation including visit assessment, OASIS, 485 and Verbal Orders accurately and promptly on the laptop device or in written documentation while in the patient's home and within the agency's and regulatory standards. Data syncs (transmits) information same day. Exercise independent judgment in matters concerning emergent and non-emergent patient care needs and communicate with the physician Participates in on-call coverage rotation for the agency