Job Code:

Location: lynn

Department: clinical

All Care Division:



Position Summary:

The RN will PDN is responsible for the implementation of health care services that reflect the Agency’s philosophy and standards utilizing the nursing process.  To assess, plan, implement, and evaluate interventions to meet identified physical, social, and mental health needs of the clients he/she services. 



All Care is committed to Service Excellence, outstanding communication and exceeding the expectations of those we serve, including our patients, our referral sources, those who support our agency and each other.  The agency recognizes employees who deliver on this commitment through a formal recognition program.  At minimum, All Care expects each employee to maintain a positive, respectful attitude, to demonstrate flexible and efficient time management, to meet departmental productivity standards, while keeping current the necessary skills to work in the home care environment.  Each employee is expected to maintain open, honest and appropriate confidential communications with all customer groups in order to foster an effective service environment. 





  • Completing and signing the designated screen tool for Mass Health payment. 


  • Complete the MDS-HC or CDS and other nursing assessments and coordinate all other clinical assessments. 


  • Develop and review on an on-going basis each members Adult Foster Care plan of care. 


  • Selecting, training, evaluating, and supervisions, Adult Foster Care caregivers in conjunction with the care manager. 


  • Conduct an orientation for each Adult Foster Care caregiver before the Adult Foster Care caregiver begins personal care and provide ongoing training on health and aging. 


  • Monitor the health status of all members to ensure that all needed Adult Foster Care is properly delivered.  


  • Review the physician summary. 


  • Periodically reviewing AFC caregiver logs. 


  • Reporting any changes in the member’s status of any to the member’s physician. 


  • Conduct on-site visits with each member at the qualified setting bimonthly, alternating with the bimonthly visit by the care manager for Level 1, and monthly or more often as the member’s condition warrants for Level II.   


  • Submitting a semiannual health-status report to the member’s primary care physician. 


  • Complete nursing progress notes corresponding with each on-site visit or encounter, or encounter, or more often as the member’s condition warrants and submit a semiannual health-status report to the member’s primary care physician. 


  • Plan for all implementing discharges from the AFC program. 




  • Comply with infection control and safety measures in accordance with the policies and procedures. 





Experience, Education and Licensure 

Graduate of an NLN accredited school of nursing, two years recent experience in the direct care of the elderly or disabled adults.  Requirements include current RN license in the state where client services are being rendered. Employee must have a valid driver’s license. Furthermore, employee shall have use of a vehicle during working times and insurance as a driver of that automobile. Must be familiar with MS Word, Outlook and Excel. 


Language Skills 

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.  Ability to write routine reports and correspondence.  Ability to speak effectively before groups of customers or employees of organization. 



Physical Demands 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 


While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee must regularly lift and/or move 50 pounds and frequently lift and/or move up to 100 pounds.  Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. 


Agency Expectation of Employee:
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