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Summary of Position

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

Essential Duties and Responsibilities

1. Administrative Functions

a. 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 RAPs and Triggers.

b. Maintain and periodically update written policies and procedures that govern the development, use, and implementation of the resident assessment (MDS) and care plan.

c. Perform administrative duties such as completing medical forms, reports, evaluations, studies, etc., as necessary.

d. Develop, implement, and maintain an ongoing quality assurance program for the resident assessment and care plans.

e. Assist the resident and Discharge Planning Coordinator in completing the care plan portion of the resident's discharge plan.

f. Participate in Facility surveys (inspections) made by authorized government agencies.

g. Monitor the Facility's QI and QM reports to ensure that appropriate corrective action can be implemented when potential problems areas occur.

h. Ensure that all assessments are completed and transmitted in a timely manner. Report problem areas to the Administrator.

i. Ensure that a current copy of the MDS Instructor's Manual is available to persons completing portions of the MDS.

2. Personnel Functions

a. Maintain an effective, friendly working relationship with health professionals, physicians, consultants, and governmental agencies that may be involved in the resident assessment and care plan functions of the Facility.

b. Meet with and solicit advice from department supervisors concerning the resident assessment and care plan functions of the Facility.

3. Nursing Care Functions

a. Develop and implement procedures with the Director of Nursing Services to inform all assessment team members of the arrival of newly admitted residents.

b. Assist Facility directors and supervisors in scheduling the resident assessment and care plan meetings.

c. Contact and assist in scheduling participation by outside members of the care plan team, including the resident's representative and/or other interested family members.

4. Therapy Functions

a. Assist in interviewing residents to evaluate daily living skills and capacities and determine extent of abilities and limitations.

b. Assist in determining appropriate treatment, selecting activities and exercises based on medical and social history of residents.

c. Participate in the development and implementation of resident assessments (MDS) and care plans, including quarterly and annual reviews.

d. Assist in scheduling therapy services.

e. Assist occupational therapist in therapy activities.

f. Brief resident on procedures involved in occupational therapy and prepare necessary equipment.

g. Assist in transporting resident to and from occupational therapy room or area.

h. Demonstrate to residents and staff personnel the procedures involved in the treatment process, as necessary.

i. Perform occupational therapy in the resident's room, if necessary.

j. Reassure resident before and during therapy session.

k. Prepare resident for treatment and administer occupational therapy in accordance with established policies and procedures.

l. Instruct and supervise resident during therapy.

m. Assist in designing and adapting equipment and living environment.

n. Teach basic living skills to residents, as necessary.

o. Promote participation in individual and group recreational activities.

p. Recommend modifications and changes in the resident's therapy treatment, as indicated.

q. Ensure that all therapists' notes are informative, follow guidelines, and are descriptive of the care provided and of the resident's response to the care.

r. Provide individualized occupational therapy services to residents according to the resident's Plan of Care.

5. Staff Development

a. 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.

b. Assist in developing any training activities needed concerning resident assessment and 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.).

c. Attend and participate in annual Facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.)

d. Attend and participate in advance directive in-service training programs for the staff and community.

e. Attend and participate in continuing education programs designed to help you keep abreast of changes in your profession, as well as to maintain your license on a current status.

f. Conduct training programs for appropriate staff on the completion and use of the MDS.

6. Care Plan and Assessment

a. Develop preliminary and comprehensive assessments of the nursing needs of each resident, utilizing the forms required by current rules or regulations and Facility policies.

b. Ensure that appropriate health professionals are involved in the assessment.

c. 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.

d. Coordinate the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems and 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.

e. 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.

f. Ensure that an initial resident assessment is completed within fourteen (14) days of the resident's admission.

g. Ensure that a comprehensive care plan is completed within twenty-one days (21) of the resident's admission.

h. 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.

i. Develop the schedule of activities required for the resident assessment and plan of care.

j. Assist the Director of Nursing Services and relevant directors and 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.

k. Ensure that quarterly and annual resident assessments and care plan reviews are made on a timely basis.

l. Ensure that a complete resident assessment is conducted within fourteen (14) days of a significant change in the resident's condition.

m. 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.

n. Assist the Director of Nursing Services and other relevant directors and supervisors 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.

o. Inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS).

p. Ensure that each portion of the assessment is signed and dated by the person completing that portion of the MDS.

q. Sign and date the assessment instrument to certify its completion.

r. Ensure that medical and nursing care is administered in accordance with the resident's wishes, including the implementation of advance directives.

7. Resident Rights

a. Honor the resident's refusal of treatment request. Report such action to your supervisor.

b. Abide by the resident's participation in treatment decision.

c. Inform the resident of consequences of not participating in prescribed therapy and document such action in the resident's clinical record.

d. Report any complaints or grievances to the department supervisor.

e. Report and investigate all allegations of resident abuse and/or misappropriation of resident property.

f. Allow the resident to participate in the planning and scheduling of his or her treatment.

g. Must adhere to all HIPAA requirements.

Qualifications
•Must possess a current, unencumbered, active license to practice as a Licensed Practical Nurse in this state.
•Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served.
•Must be able to read, write, speak, and understand the English language.
•Must be a supportive team member, contribute to and be an example of team work and team concept.
•Must possess the ability to make independent decisions when circumstances warrant such action.
•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 leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
•Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.

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