SUMMARY:

Primarily responsible for participating in the development of the minimum data set (MDS) resident assessment and care plans for all residents in the Health Care Unit.

ESSENTIAL DUTIES AND RESPONSIBLITIES:

Participates in the development and completion of the minimum data set (MDS) resident assessment in accordance with current rules, regulations, and guidelines that govern the resident assessment.

Performs portions of resident admission evaluations/assessments and ongoing resident evaluations/assessments in accordance with an established schedule. Interviews residents, his/her family, staff and contractors and utilizes information to complete the MDS assessment as is required.

Performs other miscellaneous evaluations/assessments as assigned (Range of Motion, Safe Handling, Braden).

Monitors Resource Utilization Groups (RUG’s) and case mix on MDS in relation to resident’s needs, to assure that the appropriate RUG’s/case mix is being documented.

Monitors documented therapy times/notes to ensure that these correlate with the MDS documentation and resident Plan of Care.

Submits MDS data to the proper state agencies within required time frames.

Maintains knowledge of Ohio Department of Health Long Term regulations.

Complies with written policies and procedures related to the development, use, and implementation of the MDS and care plan.

Tracks, generates, and mails physician certification/re-certification sheets in accordance with facility policies/procedures.

Assists the Resident Falls Program coordinator with development of interventions and documentation requirements related to resident falls.

Performs regular, ongoing comprehensive medical records reviews, to ensure that documentation of care/services supports the MDS and Care Plan, and to identify new resident issues that need to be addressed on the MDS.

Provides verbal and written reports to the Quality Improvement Committee, the Director of Nursing, and the President/CEO/Administrator about activities related to MDS development and maintenance.

Serves on various committees as assigned, including, but not limited to:

• Weekly Medicare Utilization Committee
• Quality Improvement Committee as is required.

Assists in discharge planning as needed.

Provides direct resident/nursing care as necessary to ensure that resident needs are being met in a timely manner.

Participates in facility surveys/inspections. Communicates effectively with surveyors/inspectors.

Utilizes Hill View’s computer information system to assess and share required information with other staff members. 

Follows HIPAA security policies/procedures.