Develop preliminary and comprehensive assessments of the nursing needs of each resident, utilizing the forms required by current rules or regulations and facility policies.
Ensure that appropriate health professionals are involved in the assessment.
Ensure all MDS 3.0 Resident Interviews are completed/documented timely. If resident was unable to complete interview, ensure staff interviews are completed/documented timely.
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 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 the care plan includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the resident's assessment.
Ensure that an initial resident MDS 3.0 assessment is completed within fourteen days of the resident's admission.
Ensure all applicable scheduled/unscheduled PPS assessments are completely timely.
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.
Develop the schedule of activities required for the resident assessment and plan of care.
Assist the Director of Nursing Services and relevant directors/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.
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.
Inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS).
Ensure that each portion of the MDS 3.0 assessment is signed and dated by the person completing that portion of the MDS.
Sign and date the MDS 3.0 assessments to certify completion.
Ensure timely electronic submission of all required MDS 3.0 assessments and tracking are transmitted timely with timely review of validation reports with all warning/rejection messages addressed.
Care Area Assessments (CAAs):
Review the Care Areas Assessments with related Care Area Triggers (CATs) 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 CAA summary sheet and verify that all triggered CAAs and corresponding narrative summaries have been completed, dated, and signed by the appropriate disciplines.
For triggered CAAs included in the Care Plan, verify that any additional supportive documentation related to CAA issues is completed.
If a triggered CAA is not included in the Care Plan, verify that documentation in the CAA summary clearly indicates reasons for not proceeding
Disseminate any new or updated materials involving MDS 3.0 ad 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 case mix scores and how they impact reimbursement.
Lead the daily PPS and Utilization Review Meeting, ensure all applicable IDT members are present/participate.
Lead the weekly Triple Check IDT Meeting, ensure all applicable team members are present/participate.
Lead the weekly Case Mix Review Meeting.
Participate in resident admission referral process.
Case Management - Provide resident clinical update and re-certification information to Managed Care Providers Case Managers in a timely manner.
Participate in the weekly Standards of Care Meeting.
Lead all scheduled Resident Care Conferences/Care Plan Review meetings.
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.
Educate peers on MDS 3.0, CAAs, 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
Capital Health Services - Shiloh Springs