Job Description

PURPOSE OF THE JOB

The primary purpose of this position is to conduct and coordinate the development and completion of the resident assessment in accordance with the requirements of this state and the polices and goals of this facility.

Every effort has been made to identify the essential functions of this position; however, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

SAFETY FACTORS:

Risk Potential to Blood/Body Fluids:

Category I : Tasks in this category involve exposure to blood, body fluids, or tissues, and require the use of personal protective equipment.

Category II : Tasks in this category involve no exposure to blood, body fluids, and/or tissues, but employment may require performing unplanned category I tasks.

Category III : these tasks require no exposure to blood, body fluids, and/or tissues, and category I tasks are not a condition of employment.

ESSENTIAL JOB FUNCTIONS & RESPONSIBILITIES:

Administrative Functions

• Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations and guidelines that govern the resident assessment, including the implementation of CAAs and Triggers.
• Maintain and periodically update written policies and procedures that govern the development, use and implementation of the resident assessment (MDS) and care plan.
• Develop, implement and maintain an ongoing process for the resident assessment/care plans.
• Assist the resident and discharge planning coordinator (Social services) in completing the care plan portion of the resident’s discharge plan.
• Oversee the daily Utilization Review/ Case Management Review meeting which includes the interdisciplinary team and is intended to foster daily communication of client needs and changes in status which may impact the plan of care.
• Participate in facility surveys (inspections) made by authorized government agencies.
• Participate per rotating schedule (at administrator’s direction) in a weekend manager program. This does not include a weekend/holiday on call rotation schedule.

Committee Functions:

• Work with the Interdisciplinary Care Plan Team in developing a comprehensive resident assessment and care plan for each resident.
• Serve on, participate in and attend various other committees of the facility (i.e. Quality Assessment and Assurance) as required and as appointed by the Administrator.
• Participate in functions involving discharge plans as may be necessary.
• Evaluate and implement recommendations from the interdisciplinary team as it may pertain to the assessment and/or care plan functions of the facility.
• Work collaboratively with nursing team to review quality measures on a routine basis.
• Participate in weekly meeting with rehab manager to review therapy caseload and therapy needs.

Personnel Functions:

• Maintain an effective, friendly working relationship with health care professionals, physicians, consultants and governmental agencies that may be involved in the resident assessment/care plan functions of the facility.
• Meet with and solicit advice from department supervisors concerning the resident assessment/care plan functions of the facility

Nursing Care Functions:

• Conduct or coordinate the interviewing of each resident for the resident assessment for designated sections of the MDS.
• Evaluate each resident’s condition and pertinent medical data to determine any need for a significant change in status assessment or the need to revise the resident’s care plan to appropriately reflect current status.
• Assist with facility’s interdisciplinary team in scheduling the resident assessment/care plan meetings.
• Assist social services with implementation of care conference schedule and inclusion of the resident and the resident’s representative and/or other interested family members.
• Ensure that care plan is implemented per the resident’s wishes.

Staff Development:

• Develop and participate in the planning and conducting of timely in service training for direct care staff including, but not limited to, ADL training, resident centered care planning, and appropriate documentation reflecting resident status.
• Attend and participate in continuing education programs designed to help you keep abreast of changed in your profession, as well as to maintain your license on an active status.

Care Plan and Assessment Functions:

• Ensure that appropriate health professionals are involved in the assessment process.
• Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions and that they are aware of the penalties, including civil money penalties for false certification.
• Coordinate the development of a resident centered comprehensive plan of care for each resident that identifies the problems/needs of the resident, goals to be accomplished, and interventions to be implemented to attain goals that have been set.
• Ensure that the care plan includes measureable objectives and timetables to meet the resident’s medical, nursing and mental and psychosocial needs as identified in the resident’s assessment.
• Ensure that the initial resident assessment is completed within fourteen days of the resident’s admission.
• Ensure that PPS schedule is followed per Medicare guidelines, including timeliness of opening and completing scheduled PPS assessments as well as unscheduled OMRAs and Medicare end of stay assessment when appropriate.
• Ensure appropriate completion of section GG when appropriate, including daily interdisciplinary discussion, progress note regarding goals set by day 4, and completion of goals met review during 3 days prior to planned discharge.
• Ensure that a comprehensive care plan is completed within twenty-one days of the resident’s admission.
• Assist the nursing staff in encouraging the resident and his/her family to participate in the development and review of the resident’s plan of care.
• Assist the Director of Nursing and relevant supervisor of other departments in ensuring that all personnel involved in providing care to the resident are aware of the resident’s care plan and that nursing personnel refer to the residents care plan prior to administering daily care to the resident.
• Ensure that quarterly and annual resident assessments and care plan reviews are made on a timely basis.
• Ensure that a complete resident assessment is conducted within fourteen days of a significant change in the resident’s condition.
• Coordinate the review and revision of the resident’s care plan by the interdisciplinary team after each quarterly review or other assessment, assuring that the care plan is evaluated and revised each time an assessment is done or when there is a change in the resident’s status.
• Assist the Director of Nursing and other relevant directors and supervisor in maintaining good rapport and morale between and within departments to ensure that a team effort is achieved in developing and implementing a comprehensive assessment and plan of care.
• Inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS).
• Ensure that each portion of the assessment is signed and dated by the person completing that portion of the MDS.
• Sign and date the assessment instrument to certify its completions.

Resident Rights

• Maintain the confidentiality of all resident care information.
• Ensure that all residents are treated fairly, and with kindness, dignity, and respect.
• Ensure that resident interviews are conducted in private.
• Ensure that all members of the assessment team and the interdisciplinary care planning/medical and nursing team are knowledgeable of the resident’s responsibilities and rights including the right to refuse treatment.
• Ensure that nursing staff members honor the resident's refusal of treatment request, and that such requests are in accordance with the facility's policies governing advance directives, including review with the resident and/or representative.
• Ensure that the facility’s policies and procedures governing advance directives are reviewed with the resident and/or representative.
• Review any complaints or grievances made by the residents regarding the resident assessment or care plan.
• Ensure that a written record is made of any resident’s complaints or grievances with a full accounting of any actions taken and the current status of the complaint.
• Report to the appropriate authorities and investigate all allegations of resident abuse and/or misappropriation of resident property immediately as determined by policy and procedure; in accordance with state and federal regulations.

Working Conditions

• Works in office areas and throughout the nursing service area (i.e., drug rooms, nurses' stations, resident rooms, etc.). Moves intermittently during working hours.
• Subject to frequent interruptions.
• Subject to hostile and emotionally upset residents, family members, personnel, and visitors under all conditions and circumstances.
• Communicates with the medical staff, nursing personnel and other department supervisors.
• Works required hours per hired agreement and additional hours per facility needs at administrative request.
• Is subject to call back during emergency conditions (i.e. severe weather, evacuation, post disaster, etc.)
• Is involved in community/civic health matters/projects as appropriate.
• Attends and participates in continuing education programs.
• Subject to injury from falls, equipment burns, odors, etc., throughout the workday, as well as potential reactions from dust, disinfectants, and air contaminants.
• Subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
• May handle or be exposed to hazardous chemicals.
• Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the resident’s needs.

Education Requirements

• Must possess, as a minimum, an LPN/RN Nursing degree from an accredited college or university.
• RN preferred

Specific Requirements

• Must possess a current, unrestricted, active state license as a Licensed Practical Nurse or a Registered Nurse in this state.
• Must be able to read, write, speak, and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must be able to relate to and work tactfully with ill, disabled, elderly, emotionally upset, or hostile people. Must have patience, tact, enthusiasm, and the willingness to handle difficult people and situations.
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
• Must possess leadership and supervisory ability and the willingness to work harmoniously with other managers and employees.
• Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., necessary for providing quality care.
• Must be able to function independently, and have the flexibility, personal integrity, and ability to work effectively with residents, staff, and support agencies.
• Must be open to change and willing to seek out new methods and principles and incorporate them into existing nursing and administrative practices.
• Must be able to relate information concerning a resident’s condition.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical and Sensory Requirements (with or without the aid of mechanical devices)

• Must be able to move intermittently throughout the workday.
• Must be able to speak and write English language in an understandable manner.
• Must be able to cope with mental and emotional stress.
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
• Must meet the general health requirements set forth by the policies of this facility that include a medical and physical examination.
• Must be able to relate to and work with the ill, disabled, elderly, emotionally upset and at times hostile people within the facility.
• Must be able to push, pull, move, and/or lift a minimum of 25 pounds.
• Must be able to assist with emergency evacuation of residents.

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