MDS / Care Plan Nurse

DEPARTMENT : Administration

SUPERVISOR : Director of Nursing and / or Corporate Designee

POSITION SUMMARY :

The MDS / Care Plan Nurse is responsible for the completion and submission of MDS assessments accurately and timely. MDS / Care Plan Nurse also creates and maintains current, individualized plans of care for each resident they are assigned to. The MDS / Care Plan Nurse ensures that all residents receive quality care and that all essential needs are met.

DUTIES AND RESPONSIBILITIES :

The following represents the essential functions of the MDS / Care Plan Nurse's role. This list is intended to be a general description of duties and responsibilities; however, it is subject to change according to the needs of the facility determined by the Director of Nursing and / or Corporate Designee.

• The MDS / Care Plan Nurse will complete and submit MDS assessments accurately and timely.
• The MDS / Care Plan Nurse will create and maintain current, individualized plans of care for each resident they are assigned to.
• Care plans will be adjusted when there is an incident / accident, status change, diet change, psychosocial changes, new or resolved diagnosis, or other relevant changes.
• The MDS / Care Plan Nurse will inform department managers of upcoming due dates or changes in ARD dates. They are responsible for following up with department managers who are responsible for completing MDS assessment sections. Should there be consistent issues with completion, MDS / Care Plan nurse should notify the Director or Nursing and / or Administrator.
• MDS / Care Plan Nurse should read and maintain supporting documentation for assessments.
• MDS / Care Plan Nurse will assist Nursing Supervisors in training new hires on documentation related to MDS assessments. Competencies upon hire and annually should be completed.
• MDS / Care Plan Nurse will continually assess how staff completes documentation needed for MDS assessments to determine training needs. Nurse can meet with staff as a group or individually- whichever is most appropriate.
• MDS / Care Plan Nurse will communicate to the Administrator or Corporate Designee regarding claims, denials, record requests, and audits. MDS / Care Plan Nurse will be required to be present during all MDS audits.
• MDS / Care Plan Nurse must be present for any state or federal agency surveys.
• The MDS / Care Plan Nurse will investigate and assist in claim resolution.
• MDS / Care Plan Nurse will maintain compliance with Medicare / Medicaid rules and regulations.
• MDS / Care Plan Nurse will coordinate the assessment schedule with the interdisciplinary team to ensure timeliness of assessments and maximize reimbursement.
• The MDS / Care Plan Nurse participates in Daily QA (morning) Meetings, Monthly / Quarterly QA, High Risk Meetings, Safety Committee Meetings, Resident Council Meetings when requested, Care Plan Meetings, in-service trainings, continuing education programs, and all other meetings called by Legacy or licensing entities.
• The MDS / Care Plan Nurse is a member of the Interdisciplinary Team (IDT Team).
• The MDS / Care Plan Nurse will make introductory visits with new residents and employees timely.
• The MDS / Care Plan Nurse attends new hire orientation program when requested to greet and brief new employees on MDS / Care Plan Nurse's role in the building.
• The MDS / Care Plan Nurse may be on the nursing on-call schedule and be required to fill floor shifts as needed.
• Must act in ways that promote professional and positive representation of the facility to the community.
• Communicates in a professional and courteous manner using effective verbal and non-verbal communication skills with residents, their families, co-workers, and vendors.
• Maintains confidentiality of department, resident, employee information, communication, and documentation as well as compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations.
• Clocks in and out for all working / training hours. Working off the clock will not be permitted at any time or for any reason.
• Maintain compliance with Legacy's Compliance program and plan.
• Adhere to Legacy's Code of Conduct and Dress Code.
• These duties are not all-inclusive but provide minimum performance expectations which will be reviewed in the evaluation process. Supervisor may edit, alter, add to, or exclude duties and responsibilities based on the needs of the facility.

QUALIFICATIONS / EXPERIENCE / REQUIREMENTS :

Minimum Qualifications

o Freedom from illegal use of drugs.

o Freedom from use and effects of drugs and alcohol in the workplace.

o Anyone found guilty by a court of law of abusing, neglecting or mistreating individuals in a health care related setting are ineligible for employment in the position.

Education and / or Experience

o Completion of an accredited nursing program

o Experience in Long-Term care setting preferred but not required.

Certifications, Licenses, Registrations :

o Active LPN / LVN or RN License (appropriate state)