The Registered Nurse (RN) is
responsible for identifying the treatment needs of the clients and making sure
they are met in accordance with agency policies, procedures, state and federal
guidelines and regulations. The RN will work with nursing staff to cover all RN
needs of Opioid Treatment Program as well as integrated, mental health and
substance abuse services.
Must be licensed as a Registered
Professional Nurse in New York State preferably with experience in the Chemical
Dependency and/or Mental Health field; support the approach of Person Centered
Care and must subscribe to a Professional Canon of Ethics.
The overall responsibilities of
this position that cannot be delegated include:
• Responsible for adhering to standards of care to
insure program clients receive preventative, routine, ongoing, follow up and
emergency medical services.
• On a daily basis the RN is responsible for
delivering optimal care by:
• Assessing and coordinating the medical and
behavioral health needs of program clients.
• Monitoring the health and well-being of clients.
• Accurately documenting all medical services,
individual and group services provided to clients.
• Communicating with medical service providers,
client emergency contacts, and program staff, and then documenting the
communication.
• Managing and responding to medication calls from
clients and pharmacies.
• Maintaining the
clinical chart in accordance with Credo policy and procedure, OASAS regulation,
HIPAA, and 42 CFR.

• Reviewing the proper distribution,
administration and documentation of the administration of medications given
• Reporting any and all medication or
documentation errors, as outlined in Credo policy and procedure, to a program
Director or his/her designee.
• Insuring all prescribed and over-the-counter
medications are secured, inventoried, administered and recorded in compliance
with Credo policies and procedures.
• Obtain patient history, take vitals, and develop
patient care charts, ensuring completeness and accuracy.
• Educate and counsel patients on disease
prevention and healthy lifestyle habits;
• emphasize preventative care and disease
management.
• Support the efforts of staff to assess and
triage patients for appropriate levels of care and risk (ie. COWS assessment,
vital signs), determine need for referral to Physician or another agency, and
assist with medical assessment, identification of symptoms and refer for
evaluation and/or care
• Implement interventions to support and
assist the client in regaining optimal health.
• Maintain the Nursing station to meet
program needs.
• Provide support as needed for medical
related services to agency medical providers, ie. MD, NPP
• Completes daily inventory of methadone and
suboxone in accordance with all state and federal regulations.

• Review inventory monthly with MD.
• Prepare proper set up of equipment and
administer Methadone, Suboxone and Vivitrol in accordance with all state and
federal regulations.

• Tracks client take-home schedules; maintains
lists/labels for current take-homes in case of power outage or EHR issues to
facilitate manual dispensing.
• Work with treatment team to develop the
medical plan of action as reflected in the Treatment Plan.
• Responsible for the review and completion of a
medical assessment document on all outpatient admitted clients.

• Access collateral information, including
HealtheConnections, to collaborate with other healthcare providers, share vital
data and add value to ensure quality client care and improved health outcomes.
• Prior to admission:
• Review or conduct a communicable disease risk
assessment (HIV/AIDS, tuberculosis, hepatitis, or other communicable diseases)
to determine whether or not the individual appears to be free of serious
communicable disease that can be transmitted through ordinary contact;
• conduct a toxicology screen pursuant to
provisions of this Part as clinically appropriate or as required by federal
law;
• Conduct an intradermal skin or blood based
Tuberculosis test; testing may be done on site or by referral with results as
soon as possible after admission but no later than finalization of the
treatment recovery plan;
• Prior to the development of a treatment
plan, address and document physical health as follows:
• For those patients who have not had a physical
exam within one year prior to admission, have they either been assessed
face-to-face by a member of the medical staff to ascertain the need for a
physical exam OR been referred for a physical exam.
• For the patients who have had a physical exam
within one year prior to admission, or are being admitted directly to the
outpatient program from another OASAS-certified CD program, the existing
medical history and physical exam documentation may be used to comply with this
requirement provided such documentation has been reviewed by a member of the
medical staff and determined to be current.
• Provide medical monitoring services as described
in the OMH and/or OASAS outpatient regulations, including injections prescribed
or ordered by authorized prescribers.
• Review dictation/transcription as
needed for medical staff for accuracy and completeness.

• Obtain breath and urine samples for AOD testing
as needed.