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 the state and the policies and goals of this facility.

Duties and Responsibilities

1. 
   
   1. Coordinate and oversee Minimum Data Set (MDS) assessments for each resident utilizing the appropriate forms required by the type of assessment.
   2. Ensure that all assessments are completed and transmitted within required timeframes; report problem areas to the Administrator.
   3. Establish the assessment reference date (ARD), reason for the assessment, accuracy, timely completion and submission for each assessment.
   4. Initiate the opening and closing of assessments and alert the interdisciplinary team (IDT) as needed.
   5. Meet with and solicit feedback from department supervisors concerning the resident assessment/care plan functions of the facility.
   6. Participation in the facility compliance program including utilization review and monthly triple check for billing accuracy.
   7. Review medical records for accurate documentation of the resident’s condition and make recommendations for the improvement of documentation as directed.
   8. Conduct pre-admission nursing screening as directed to ensure Medicare Part A eligibility entitlement and coverage for all relevant referrals and new admissions.
   9. Develop and implement procedures with the Director of Nursing to inform all assessment team members of the arrival of newly admitted residents.
   10. Participate in functions involving discharge plans as necessary.
   11. Prepare Notices of Medicare Non-Coverage (NOMNC) within the time limits imposed by Medicare guidelines.
   12. Ensure appropriate and accurate completion of the physician certification and recertification form, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and Medicare non-coverage letter.
   13. Monitor residents for change in condition through facility IDT meetings per facility policies.
   14. Obtain appropriate qualifying diagnosis for residents obtaining Medicare Part A services and update diagnosis for each change in resident condition as appropriate.
   15. Contribute and collaborate in the development of the annual facility assessment providing updates as required.
   16. Perform administrative duties such as completing medical forms, reports, evaluations, studies, etc., as necessary.
   17. Maintain and periodically update written facility policies and procedures that govern the development, use and implementation of the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) and care plan.
   18. Develop, implement, and maintain an ongoing quality assurance and performance improvement (QAPI) program for the resident assessment/care plans.
   19. Ensure that a current copy of the RAI Manual is available to persons completing portions of the MDS.
   20. Monitor the MDS website and portal for up-to-date changes in the RAI manual monthly; distribute changes in the RAI manual to the IDT as needed.
   21. Review quality measures reports monthly and make recommendations to the QAPI Committee.
   22. Complete electronic submission of required documentation to the state database and other entities in accordance with facility policies.
   23. Conduct and coordinate the completion and submission of MDS within the required timeframe.
   24. Submit and monitor the nursing home final validation report to verify assessment submission.
   25. Transmit MDS to the Centers for Medicare and Medicaid Services (CMS) information system for each resident contained in the MDS in a format that conforms to current formatting standards within the prescribed time frames.
   26. Participate in facility surveys (inspections) made by authorized government agencies.
   27. Coordinate with therapist to report resident progress for those residents receiving direct therapy services under Medicare part A or B.
   28. Provide assistance to residents as directed and in the course of assessing residents.
   29. Assist facility directors and supervisors in scheduling the resident assessment/care plan meetings.
   30. Assist the nursing staff in encouraging the resident and his/her family to participate in the development of a person-centered plan of care; review and revise the plan of care as required.
   31. 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.
   32. 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.
   33. Coordinate the review and revision of the resident’s care plan by the IDT after each quarterly review or other assessment and assure 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.
   34. Ensure that a baseline care plan is developed within 48 hours of a new resident admission.
   35. Ensure that a comprehensive person-centered care plan is developed within 7 days after completion of the comprehensive assessment.
   36. Ensure the resident and the representative are presented with a summary of the baseline care plan.
   37. Evaluate each resident’s condition and pertinent medical data to determine any need for special assessment activities or need to revise or amend the plan of care.
   38. 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.
   39. Ensure that each portion of the resident assessment is signed and dated by the person completing that portion of the MDS.

Working Conditions

• Works in office areas as well as throughout the nursing services area (i.e., drug rooms, nurses’ stations, resident rooms, etc.).
• Moves intermittently during working hours.
• Is subject to frequent interruptions.
• Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
• Is subject to hostile and emotionally upset residents, family members, personnel and visitors.
• Communicates with the medical staff, nursing personnel and other department directors.
• Works beyond normal working hours and on weekends and holidays when necessary.
• Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
• Is involved in community/civic health matters/projects as appropriate.
• Attends and participates in continuing education programs.
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday as well as to reactions from dust, disinfectants, tobacco smoke and other air contaminants.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
• May be subject to the handling of and exposure to hazardous chemicals.
• Maintains a liaison with the residents, their families, support departments, etc., to adequately plan for the residents’ needs.

Education

• Must possess, as a minimum, a Nursing Degree from an accredited college or university.

Experience

• Must have, as a minimum, two (2) year(s) of experience as a supervisor in a hospital, nursing care facility, or other related health care facility.

Specific Requirements 

• Must possess a current unencumbered active license to practice as a Registered Nurse (RN) in the state.
• Must be able to read, write, speak and understand the English language.
• Must demonstrate the knowledge and skills necessary to prove care appropriate to the age-related needs of the residents served.
• 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 possess 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 leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
• Must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies, procedures, etc., that are necessary for providing quality care.
• Must have patience, tact, a cheerful disposition and enthusiasm as well as the willingness to handle difficult residents.
• Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
• 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.

Physical and Sensory Requirements

 (with or without the aid of mechanical devices)

• Must be able to move intermittently throughout the workday.
• Must be able to speak and write the English language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
• Must function independently and have flexibility, personal integrity and the ability to work effectively with residents, personnel and support agencies.
• Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination.
• Must be able to relate to and work with the ill, disabled, elderly, emotionally upset and, at times, hostile people within the 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