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 policies and goals of this facility.
Essential Job Functions Duties and Responsibilities
Care Plan and Assessment Functions
- Conduct and coordinate the development and completion of the Minimum Data Set (MDS) assessment in accordance with current rules, regulations, and guidelines that govern the resident assessment, including the implementation and completion of CAAs and CATs.
- Manages the reimbursement process and works collaboratively with the Business office and Therapy Department
- Assist with maintaining and updating written policies and procedures that govern the development, use, and implementation of the resident assessment (MDS) and care plan.
- Assist the resident and Discharge Planning Coordinator in completing the care plan portion of the resident's discharge plan.
- Participate in facility surveys (inspections) made by authorized government agencies.
- Ensures facility is in compliance with the RAI process
- Work with the Interdisciplinary Care Plan Team in completing a comprehensive resident assessment and care plan for each resident.
- Evaluate each resident's condition and pertinent medical data to determine any need for special assessment activities or a need to amend the admission assessment.
- Assist in scheduling participation by outside members of the care plan team, including the resident's representative and/or other interested family members. Ensure that care provided is in accordance with the resident's wishes and interests.
- Develop and participate in the planning, conducting, and scheduling of timely in service training classes that include assessment skills or techniques needed to complete the assessment functions of the facility.
- Assist the In‑service Director/Educator in developing any training activities needed concerning resident assessment/care plan skills (including, but not limited to initial or refresher courses relative to techniques for interviewing residents, rehabilitation principles, commonly used psychotropic drugs, care plan functions, etc.).
- Coordinate the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care. Ensure that appropriate health professionals are involved in the assessment. 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.
- Monitor the care plan so that it includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the resident's assessment.
- Develop the schedule of activities required for the resident assessment and plan of care.
- Assist the Director of Nursing and relevant supervisors 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 resident's care plan prior to administering daily care to the resident.
- Monitor quarterly and annual resident assessments and care plan reviews So that they are completed timely. 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.
- Monitor that medical and nursing care is administered in accordance with the resident's preferences and health care provider orders.
- Perform employee performance evaluation.
- Determine MDS staffing requirement, and making recommendations to the DON concerning employee dismissals, transfers, etc.
- Review and evaluate your team’s work process and work to improve.
- Develop work assignments and/or assist in completing and performing such assignments.
- Submit complaints and grievances DON.
Must possess the ability to make independent decisions, follow instructions, and accept constructive criticism. Must be able to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public. Must be able to work with ill, disabled, elderly, emotionally upset, and potentially hostile people within the facility. Must be able to speak and write English in an understandable manner. Must be able to speak and write English in an understandable manner.
Education and Experience
- Prefer 1 year of experience in nursing. Prefer two years experience in a long-term care facility.
- Must have experience in supervision and principles, practice of teaching, etc. Must possess skills in leadership and communication. Must possess creativity, integrity, and initiative. Must be able to provide critical thinking skills to address clinical issues. Must be proficient in Microsoft Word.
Must possess a current and active license to practice as an RN in this state.
Willingness to travel:
0 - 25%
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