- Completion of detoxification related duties such as completion of CIWA, COWS, CIWA-B, Vital Signs, Nursing Assessments, and other related IMS related functions.
- Complete daily SOAP Note and ensure records are maintained in accordance with standards of facility and state regulations.
- Observes clients, charting and reporting changes in clients’ conditions, such as adverse reactions to medication or treatment and taking any necessary action.
- Observe clients self-administering prescribed medication and document appropriately.
- Communication with IMS Physician and other outside physicians where outside referral may be indicated.
- Work with physician and pharmacy to ensure medical/nursing/medication concerns are reported and problems resolved.
- Input Doctor’s Orders and Medication Protocols in EMR
- Provide training and supervision of clients to support non-clinical staff as it relates to detox and medication protocols.
- Measures and records clients’ vital signs, such as height, weight, temperature, blood pressure, pulse and respiration, COWS/CIWAS when required
- Perform inventory check and maintenance of nursing supplies and OTC medication supplies.
- Maintain compliance with HIPAA regulations, DHCS and Joint Commission Standards
- Fully understand and maintain policies & procedures regarding professional ethics, confidentiality, and healthy boundaries.
- Fully understand our medication management policy and infection control protocol
- Completing any other duties as assigned by Registered Nurse
Required Skills/Abilities:
- Computer skills: electronic charting, word processing, spreadsheets, calendar, presentation, Internet
- Excellent written and verbal communication skills
- Train and direct others
- Quality Assurance
Education and Experience:
- Current Nursing license from the State of California and in good standing for a minimum of 5 years continuous
- Additional certifications in Pharmacology, Drug and Alcohol treatment, Mental Health, ALS, AFA. HIV certification, Medication education and management a plus.
- Minimum 5 years-experience working in Drug and Alcohol treatment (high end treatment a plus)
- Experience with electronic record systems (Kipu) or similar system and ability to learn and effectively execute The Kipu System
- Intimate knowledge of 12 step programs
- If clean/sober must maintain sobriety during employment at Hills Rehab, LLC
Physical Requirements:
- Frequent sitting must be able to remain in a stationary position at least 50% of the time
- Must be able to lift and carry light objects and parcels as an incidental part of their job
- The position needs to occasional move about inside and outside the facility frequently
- Constantly operates a computer and other office machinery
- Frequently communicates with other employees