Conduct and coordinate the development and completion of the resident assessment process in accordance with the requirements of the Federal and State regulations as well as Company policy and procedure.
Essential Job Functions:
This facility expects their employees to promote an atmosphere of teamwork with other employees and hospitality and comfort for its residents. Therefore, the following list of duties is not all-inclusive:
Minimum Data Set:
Oversee and coordinate the development and completion of the resident assessment (MDS) in accordance with current Federal and State rules, regulations, and guidelines that govern the resident assessment, including the implementation of RAPs and Triggers.
Assemble information from the Initial Nursing Assessment, resident interview, and clinical record review to complete the nursing portion of the Minimum Data Set within 10-14 days of admission or annual review, and when there is a significant change in a resident’s condition.
Notify all members of the interdisciplinary team at least one week in advance of the MDS due date for all new admissions, annual reviews, and significant changes in resident condition.
Monitor and follow-up with team members as needed to verify that all assigned sections of the MDS are completed, dated, and signed within designated time frames.
If a member of the interdisciplinary team is absent during the time frame for completion of a MDS, conduct necessary research and referral to confirm that all MDS sections and triggered RAPs are completed.
Review each MDS for accuracy, consistency, completeness, and signatures prior to submitting to the designated RN for final review and signature.
Verify that MDS documentation is placed in resident’s medical record and that documentation is complete, including dates, signatures, and sections completed by all members of the interdisciplinary team. Complete, date, and sign MDS quarterly review sheets.
Verify the face validity of all Minimum Data Sets before electronic submission.
Participate in and oversee the timely electronic submission of all MDS.
Review the validation report and verify that appropriate action is taken.
Resident Assessment Protocols (RAP):
Review the Resident Assessment Protocols correlated with nursing issues and answer the questions as identified in the computer documentation system. Once all the questions have been answered, complete narrative summaries of the information, indicating the decision whether or not to include the identified problem on the Plan of Care.
Consult the RAP summary sheet and verify that all triggered RAPs and corresponding narrative summaries have been completed, dated, and signed by the appropriate disciplines.
For triggered RAPs included in the Care Plan, verify that any additional supportive documentation related to RAP issues is completed.
If a triggered RAP is not included in the Care Plan, verify that documentation in the RAP summary clearly indicates reasons for not proceeding.
Schedule all interdisciplinary care plan meetings, and notify staff in advance which residents will be evaluated.
For Care Plan reviews, notify the resident’s family in writing 30 days in advance of care plan meeting (except for care plans requiring immediate revision due to significant change or unforeseen circumstances.)
Identify and document nursing problems, goals, and approaches, and coordinate the development of an individual Plan of Care for each resident in cooperation with the physician, Medical Director, nursing staff, interdisciplinary team, and outside consultants (nursing, dietary, pharmacy, therapists, etc.) in accordance with corporate, state, and federal guidelines.
Correlate the information to update resident care plans quarterly and after each significant change. Verify that all updates are completed. Generate final copy, and verify that signatures from the physician, interdisciplinary team, and contributing resident or family members are obtained.
Make a copy of each resident’s care plan accessible to CNAs.
Disseminate any new or updated materials involving the RAI process.
Create an opportunity for family participation in the care planning process.
Communicate with the Business Office Manager and Administrator on a regular basis regarding the case mix scores and how they impact reimbursement.
Coordinate the interdisciplinary assessment process for all residents of the facility. Verify that the Resident Assessment Instrument is individualized, complete, accurate, and timely for each resident.
Conduct and facilitate the Interdisciplinary Care Plan meetings. Educate peers on MDS, RAPs, and Care Plans.
Attend in-service education programs in order to meet facility educational requirements.
Be familiar with Standard Precautions, Exposure Control Plan, Fire Drill and Evacuation Procedures and know how to use the information.
Maintain confidentiality of resident and facility records/information.
Protect residents from neglect, mistreatment, and abuse.
Protect the personal property of the residents of the facility.
Others as directed by the supervisor or administrator.
Registered Nurse or Licensed Practical/Vocational Nurse with required state licensure.
Minimum three (3) years of clinical experience in a health care setting. Minimum of two (2) years experience in a long-term care setting.
Knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
Excellent analytical and deductive reasoning skills.
Organized and detailed in work performance.
Computer literacy and comprehensive understanding of documentation software system.
Excellent technical, assessment, documentation, and writing skills.
Good communication skills with excellent self-discipline and patience.
Genuine caring for and interest in elderly and disabled people in a nursing facility.
Comply with the Residents Rights and Facility Policies and Procedures.
Perform work tasks within the physical demand requirements as outlined below.
Perform Essential Duties as outlined above.