SUMMARY: The MDS Coordinator / Staff Educator- acts as the principal party responsible for completion of the MDS Assessment and Coordination of the Care Plan Process. The MDS Coordinator will also complete and implement all Assessments to CMS. ESSENTIAL FUNCTIONS: NOTE: Laguna Rainbow Corporation may unilaterally change the requirements of this job description at any […]
SUMMARY: The MDS Coordinator / Staff Educator- acts as the principal party responsible for completion of the MDS Assessment and Coordination of the Care Plan Process. The MDS Coordinator will also complete and implement all Assessments to CMS.
ESSENTIAL FUNCTIONS: NOTE: Laguna Rainbow Corporation may unilaterally change the requirements of this job description at any time. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. These include, but are not limited to, the following:
Personnel and Administrative Functions:
- Coordinate, implement and evaluate the RAI process for all departments involved in the Interdisciplinary Care Plan (ICP) Team approach to completing MDS Assessment Forms, CAAs, and Care Plans and make recommendations for streamlining operations.
- Conduct Care Plans in a timely, comprehensive, and efficient manner.
- Maintain a well-documented and organized assessment system which is easy and accessible to other Care Plan members in a manner others understand.
- Monitor the Care Plan Process System to ensure timely and accurate completion of MDS Assessments, CAAs, and Care Plan Decisions by the ICD team.
- Assist in the conversion of current MDS and Care Plan systems to the new Medical Communication Software System and upload MDS assessments into Abaqis.
- Ensure that Abstracts for New Medicaid Residents are done within 72 hours of admission and concurrent reviews and abstracts for continuing applications and reapplications, are completed in a timely manner. Failure to do this jeopardizes the financial functions of the facility.
- Assist Director of Nursing, BOM and Administrator in timely completion of assigned tasks and projects.
- Attendance of In-Service Education and mandatory staff meetings.
- May be required to work as Staff Nurse as needed and be on call as needed.
- Performs Assessments upon admission, quarterly, annually and/or if a change of condition occurs to obtain accurate information as required to complete the nursing sections of the MDS, and development of the care plans in association with the assessment.
- Ensure completion in its entirety all nursing sections of the MDS, and Care plans as necessary within the timeframes established by the RAI, facility, state and or federal requirements, whichever requirement is the more stringent.
- Ensure an appropriate care plan (temporary, quarterly, annual and/or change of status) is initiated for nursing identified.
- Document and attend care plan meetings and outcomes in the nurses’ note as necessary.
- Maintain a well-documented and organized assessment system which is understandable and accessible by the nursing department and other agencies such as the ombudsman program, state surveyors and consultants.
- The MDS nurse will document and organize an assessment system which is understandable and accessible by the Director of Nursing.
- Review all MDS assessments and ensure signatures are in place for completion.
- Reviews the resident’s medical record to ensure all care issues are identified and care planned accordingly.
- Attends and participates in all multi-disciplinary improvement committees and documents any care issues regarding the nursing care plans.
- Assists with in-service training programs as it relates to the MDS, RAPs, care plans and others as necessary.
- Assists in ensuring residents’ needs are met on the floor when staffing is challenged.
- Observes and assists with infection control procedures related to the Department.
- Perform any assigned duties within the scope of expertise assigned by the Director of Nursing or Administrator.
- Participate in the development, maintenance, and implementation of the facility’s Quality Assurance and Performance Improvement program for the nursing service department as directed.
- Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
- Periodically review the resident’s written discharge plan. Participate in the updating of the resident’s written discharge plan as required.
- Assist in planning the nursing services portion of the resident’s discharge plan as necessary.
- Interpret the department’s policies and procedures to personnel, residents, visitors, and government agencies as required.
- Admit, transfer, and discharge residents as required.
- Complete accident/incident reports as necessary.
- Perform administrative duties such as completing medical forms, reports, evaluations. studies. Charting, etc. as necessary.
- Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.
- Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator and DON
- Participate in daily clinical meetings.
- Report any known or suspected unauthorized attempt to access facility’s information system.
Charting and Documentation Functions:
- Transcribe physician’s orders to resident charts, cards, medication cards, electronic medication administration record, treatment/care plans, as required.
- Chart nurses’ notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident’s response to the care.
- Chart all reports of accidents/incidents involving residents. Follow established procedures.
- Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Director of Nursing.
- Make certain that appropriate documentation concerning unauthoriz.cd discharges is entered in the resident’s medical record in accordance with established procedures.
- Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.
- Sign and date all entries made in the resident’s medical record.
Drug Administration Functions:
- Prepare and administer medications as ordered by the physician.
- Verify the identity of the resident before administering the medication/treatment.
- Make certain that prescribed medication for one resident is not administered to another.
- Determine that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the Director of Nursing.
- Ensure that narcotic records are accurate for your shift.
- Notify the Director of Nursing immediately of all drug and narcotic discrepancies noted on your shift.
- Review medication cards/electronic medication administration record for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.
- Notify the attending physician of automatic stop orders prior to the last dosage being administered.
- Dispose of drugs and narcotics as required, and in accordance with established procedures.
Personnel Functions:
- Provide leadership to nursing personnel assigned to your unit/shift.
- Make daily rounds of units to determine that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Report problem areas to the Director of Nursing.
- Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments and staff within the facility to make certain that nursing services and activities can be adequately maintained to meet the needs of the residents.
- Create and maintain an atmosphere of warmth, personal interest, positive emphasis, and a calm environment throughout the unit and shift.
- Report complaints and grievances made or filed by your assigned personnel. Make an appropriate response to the Director of Nursing as required or as may be necessary. Follow facility’s established procedures.
- Receive/give the nursing report upon reporting in and ending shift duty hours.
- Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility’s policies and procedures governing accidents and incidents.
- Report known or suspected incidents of fraud to the Administrator.
- Monitor that departmental computer workstations left unattended are properly logged off or the password protected automatic screensaver activates within established facility policy guidelines.
- Comply with weekly angel rounds. Angel rounds documents are to be submitted to the Administrator no later than the close of business on Fridays.
- Email is to be checked daily throughout the day and respond to email on a timely basis.
- The Director is to attend all Mandatory meetings, with no exceptions (unless approved by the Administrator)!! Morning Stand-up is a MUST!!
- Submit department QAPI data in a timely manner.
Nursing Care Functions:
- Inform nursing personnel of new admissions, their expected time of arrival, room assignment, etc.
- Ensure that rooms are ready for new admissions as needed.
- Greet newly admitted residents upon admission. Escort them to their rooms as necessary.
- Participate in the orientation of new residents/family members to the facility.
- Make rounds with physicians as necessary.
- Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established procedures.
- Consult with the resident’s physician in providing the resident’s care, treatment, etc., as necessary.
- Review the resident’s chart for specific treatments, medication orders, diets, etc., as necessary.
- Implement and maintain established nursing objectives and standards.
- Make periodic checks to ensure that prescribed treatments are being properly administered and to evaluate the resident’s physical and emotional status.
- Determine that direct nursing care be provided by a licensed nurse, a certified nursing assistant, and/or a nurse aide trainee qualified to perform the procedure.
- Cooperate with and coordinate social and activity programs with nursing service schedules.
- Notify the resident’s attending physician and responsible party/power of attorney when the resident is involved in an accident or incident.
- Notify the resident’s attending physician and responsible party/power of attorney when there is a change in the resident’s condition.
- Assist in carrying out restorative and rehabilitative programs, including self-help and care.
- Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.
- Administer professional services such as catheterization, suction, applying and changing dressings/bandages, colostomy, drainage bags, and range of motion exercises, postmortem care. etc., as required.
- Obtain sputum, urine and other specimens for lab tests as ordered.
- Take and record vital signs as necessary.
- Monitor all residents as necessary.
- Check foods brought into the facility by the resident’s family/visitors to ensure that it is within the resident’s diet and provide consultation if necessary. Report problem areas to the Director of Nursing and Dietary Supervisor.
- Determine that personnel providing direct care to residents are providing such care in accordance with the resident’s care plan and wishes.
- Determine that all residents are checked frequently.
- Meet with residents, and/or family members, as necessary. Report problem areas to the Director of Nursing
- Admit, transfer, and discharge residents as necessary.
- Assist in arranging transportation for discharged residents as necessary.
- Monitor to make certain that discharged residents are escorted to the pick-up area.
- Inform family members of the death of the resident as needed.
- Call funeral homes when requested by the family. Monitor to determine that established post-mortem procedures are followed.
Staff Development:
- Implement and maintain an effective orientation program that orients the new employee to your shift, the, policies and procedures, and to his/her job position and duties.
- Assist in standardizing the methods in which work will be accomplished.
- Assist in training department personnel in identifying tasks that involve potential exposure to blood/body fluids.
- Assist the Director of Nursing in planning clinical supervision for nurse aide trainees.
- Attend and participate in outside training programs.
- Attend and participate in annual facility in-service training programs as scheduled (e.g., OSHA, TB, HIPM Abuse Prevention, Safety, Infection Control, etc.).
- Attend and participate in advance directive in-service training programs for the staff and community.
- Attend and participate in continuing education programs to maintain your license on a current, active status.
Safety and Sanitation:
- Monitor your assigned personnel as needed to determine that they are following established safety regulations in the use of equipment and supplies.
- Monitor that established departmental policies and Procedures, including dress codes, are followed by assigned nursing personnel.
- Determine that an adequate supply of personal protective equipment is on hand and is readily available to personnel who perform procedures that involve exposure to blood or body fluids.
- Determine that your assigned work areas (i.e., nurses’ stations, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner.
- Determine that resident rooms, treatment areas, etc. are maintained in a clean, safe way. and sanitary manner.
- Determine that nursing personnel follow established hand washing and hand hygiene techniques in the administering of nursing care procedures.
- Make certain that your assigned personnel participate in all conductions of fire safety, and disaster preparedness drills in a safe and professional manner. Participate in the implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel.
- Determine that your assigned personnel follow established infection control procedures when isolation precautions become necessary.
- Monitor to make certain that nursing personnel follow established procedures in the use and disposal of personal protective equipment.
- Participate in the maintenance of the procedures for reporting hazardous conditions or equipment.
- Ensure that all personnel wear and or use safety equipment and supplies (e.g., mechanical lifts, etc.) when lifting or moving residents.
- Report missing/illegible labels and MSDSs to the safety officer or other designated person.
Equipment and Supply Functions:
- Recommend to the Supervisor the equipment and supply needs.
- Monitor that an adequate stock level of medications, medical supplies, equipment, etc., is always maintained to meet the needs of the residents.
- Participate in the implementation of the procedures for the safe operation of all nursing service equipment.
- Ensure that only trained and authorized personnel operate our unit/shift’s equipment.
- Ensure that all personnel operate nursing service equipment in a safe manner.
- Monitor nursing procedures to determine that nursing service supplies are used in an efficient manner to avoid waste.
Care Plan and Assessment Functions
- Review care plans daily to determine that appropriate care is being given per care plan.
- Review to make certain that your nurses’ notes reflect that the care plan is being followed when administering nursing care or treatment.
- Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.
- Make certain assigned certified nursing assistants (CNAs) are aware of the resident care plans.
- Ensure that the CNAs refer to the resident’s care plan prior to administering daily care to the resident.
Budget and Planning Functions:
- Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
Resident Rights:
- Maintain the confidentiality of all residents cared information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information.
- Monitor nursing care to ensure that all residents are treated fairly, kindly, with dignity, and respect.
- Monitor clinical staff to ensure that all nursing care is provided in privacy and that nursing service personnel knock before entering the resident’s room.
- Ensure that all nursing service personnel are knowledgeable of the residents, responsibilities and rights including the right to refuse treatment.
- Report complaints and grievances made by the resident and make a written/oral report to the Administrator & SSD indicating what action(s) were taken to resolve the complaint or grievance. Follow facility’s established procedures.
- Determine all nursing care is provided in privacy and that nursing service personnel knock before entering the resident’s room.
- Performs additional duties as assigned.
REQUIRED QUALIFICATIONS (includes education, skills, and experience): The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must possess, as a minimum, a Nursing Degree from an accredited college or university.
- Must have, as a minimum, two (2) years of Geriatric Experience or two (2) years as MDS/CP Coordinator.
- Must possess a current, unencumbered, active license to practice as a Registered Nurse in this state.
- Ability to communicate effectively with members of Interdisciplinary Care Team.
- Evidence of Genuine, Caring and Concern for working with the elderly population.
- Excellent Oral and Written Presentation Skills.
- Knowledge of Software Relating to Electronic Reporting of Resident Condition Based on the RAI Process mandated by HCFA.
- Must be able to read, write, speak, and understand the English language.
- Leadership skills and ability and willingness to work harmoniously with and supervise other personnel.
- Must be a supportive team member, contribute, and be an example of teamwork and team concept.
- The ability to make independent decisions when circumstances warrant such action.
- The ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
- Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities.
- Must possess the ability to plan, organize, develop, implement, and interpret the program goals, objectives, policies, and procedures, etc., that are necessary for providing quality care.
- Must have patience, tact, cheerful disposition, enthusiasm, and the willingness to handle challenging residents.
- 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.
- Intermediate to advanced skill level in Microsoft Office or similar software applications.
- Ability to use office equipment such as computers, phones, photocopiers, filing cabinets and fax/scan machines.
- Ability to multi-task, work successfully under pressure, and effectively prioritize and manage time and workload.
- Willingness and ability to seek out new methods and principles and be willing to incorporate them into existing activity services.
- Possession of excellent communication skills and ability to convey information concerning a resident’s condition.
- The ability to cope with the mental and emotional stress of the position.
- Must have a good driving record, valid, driver’s license, vehicle insurance and a reliable vehicle.
WORKING CONDITIONS AND PHYSICAL EFFORT: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Will have repetitive hand and arm motions and prolonged periods of sitting and/or standing.
- While performing the duties of this job the employee is regularly required to stand; walk; talk, listen, reach with hands and arms, climb, balance,; stoop, kneel, crouch, and crawl.
- This position requires frequent manual dexterity in combination with eye/hand coordination such as keyboarding and handling of equipment.
- Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus.
- Must meet the general health requirements set forth by the policies of this facility.
- Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.
- May be necessary to assist in the evacuation of residents during emergency situations.
- Tasks assigned to this position may involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants and hazardous chemicals.
- The noise level in the work environment is usually low to moderate with intermittent longer periods.
BACKGROUND INVESTIGATION REQUIREMENTS:
Laguna Rainbow Corporation has a strict policy for background investigation processes. Every position is reviewed and screened. This includes Onsite pre-employment drug screening, criminal background check (includes fingerprint) and license verification.
