· Conduct and coordinate the development and completion of the resident assessment (MDS) according to current rules, regulations and guidelines set forth in the RAI User manual, including the implementation of Care Area Triggers and Care Area Assessments.
· Manage RAI process and Care Plans according to VHS standards.
· Complete medical forms, reports, evaluations, and studies as directed.
· Develop, implement and maintain an ongoing quality assurance program for the resident assessment/care plans.
· Participate in facility surveys and the development of a plan of correction as it relates to deficiencies sited in the resident assessment/care plan areas.
· Schedule resident assessment/care plan meetings and inform appropriate department supervisors accordingly.
· Assist in contacting outside members of the care plan team, including resident’s representative/family members regarding participation in care plan meetings.
· As required, communicate with fiscal intermediary concerning rates and obtain additional coverage for residents as necessary.
· Conduct or coordinate the interviewing of each resident for the resident’s assessment. Ensure that appropriate health professionals are involved in the assessment.
· 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.
· Coordinate with the Director of Nursing to inform all assessment team members of the assessment date of newly admitted residents.
· Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment and that they are aware of penalties, including civil monetary penalties for false certification.
· Coordinate the development of a written plan of care (interim and comprehensive) for each resident that identifies the problems/needs, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care.
· Ensure that the care plan includes measurable objectives and timetables to meet the resident’s medical, nursing and mental and psychosocial needs.
· Ensure that an initial resident assessment is completed within fourteen days of the resident’s admission.
· Ensure that a comprehensive care plan is completed within twenty-one days of the resident’s admission.
· Encourage the resident and family members to participate in the development and review of the plan of care.
· Develop the schedule of activities required for the completion of the Resident’s assessment process.
· Assist the Director of Nursing Services and relevant supervisors in ensuring that all personnel providing direct care to the resident are aware of the plan of care and that they refer to the care plan prior to administering daily care.
· Ensure that quarterly and annual MDS and care plan reviews are completed per the schedule in the RAI Manual.
· Ensure that a complete assessment is conducted within fourteen days of a significant change in the resident’s condition.
· Coordinate the review and revision of the care plan by the interdisciplinary team (including hospice, if appropriate) after each quarterly review to ensure that the care plan is revised to reflect the change in status.
· Assist the DON and other relevant supervisors in maintaining good rapport and morale between and within departments to ensure a team effort in providing consistent quality care.
· Ensure that each portion of the assessment is signed and dated by the person completing that portion of the MDS.
· Sign and date the MDS to certify its completion.
· Transmits MDS per state and federal regulations.
· Must possess a current, unencumbered, active license to practice as a RN in this state.
· At least one (1) year experience in rehabilitative and restorative nursing or as a staff nurse in a health care facility. Experience in long-term care required.