MDS Coordinator

Required Qualifications

An unencumbered nursing license in the state RN.

Must have, as a minimum, one (5) year of experience with demonstrated success in a nursing position in the facility or in another related health care facility.

Knowledgeable of nursing and medical practices and procedures, as well as laws, regulations and guidelines pertaining to long-term care.

Knowledgeable of skilled nursing home regulations, procedures, laws, regulations and guidelines pertaining to long-term care.

Major Duties and Responsibilities

Plans, develops, organizes, implements, evaluates and directs the quality assessment and assurance (QA&A) program and quality assurance performance improvement (QAPI) activities of the facility in accordance with current state and federal laws and regulations.

Identifies, in conjunction with the Administrator, Director of Nursing Services and selected department heads, the facility’s key performance indicators. Establishes an ongoing system to monitor these key indicators throughout the facility to promote improvements, enhance resident care delivery systems, maintain regulatory compliance and/or promote customer satisfaction.

Similarly, evaluates key performance indicator outcomes with department heads to determine the need for action from leadership and/or management such as re-education or revisions in facility policies related to outcomes, regulatory compliance and/or customer satisfaction.

Develops and implements the facility’s QA&A/QAPI activities according to the facility’s QAPI Policy and Procedure including feedback, data collection systems, and monitoring methods.

Coordinates the process by which the QA&A/QAPI committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following:

· Establishing goals and thresholds for performance improvements.

· Identifying and prioritizing quality deficiencies.

· Systematically analyzing underlying causes of systemic quality deficiencies.

· Developing and implementing corrective action or performance improvement activities.

· Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

Prioritizes program activities that focus on high-risk, high-volume, or problem-prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves.

Leads and coordinates monthly QA&A/QAPI team meetings to discuss priorities and develop solutions with facility leaders such as falls, weight loss, pressure ulcers/injuries, decline in late loss ADL’s, activity participation, life safety code, cleanliness, lost laundry, etc.

Develops and maintains existing tracking systems, forms, grids, and/or charts to monitor key performance indicator outcomes in the facility. Recommends changes or additional tracking systems needed to Administrator and/or Director of Nursing Services.

Coordinates quality assessment and assurance monitoring and tracking activities with the facility management/leadership daily, weekly, monthly and as needed.

Coordinates data collection from all departments to develop and monitor performance indicators.

Communicates the facility’s QAPI plan and/or changes in the plan, on an as needed basis but not less than monthly to members of the facility’s governing body/leadership team - more frequently when directed by the Administrator or Director of Nursing Services.

Maintains a commitment to quality assessment and performance improvement.

Develops, implements and maintains a process to ensure care and services delivered meet accepted standards of quality.

Maintains documentation of the facility’s QA&A/QAPI program activities that demonstrate evidence of its ongoing program. Documentation may include, but is not limited to:

· The written QAPI plan.

· Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events.

· Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities.

Collects data for the QA&A/QAPI program from multiple sources, including input from all staff, residents, families, and others as appropriate. Data sources may include, but are not limited to:

· The facility assessment.

· Grievance logs.

· Medical record and drug regimen reviews.

· Skilled care claims.

· Clinical logs such as for falls, pressure injuries, and weights.

· Staffing trends.

· Incident and accident reports, including reports of adverse events or abuse, neglect, or exploitation.

· Quality measures.

· Survey outcomes.

· Staff, resident, and family satisfaction surveys.

Maintains sample data collection forms with the written QA&A/QAPI plan.

Develops and implements appropriate plans of action to correct identified deficiencies internally at the facility level and as identified by the licensure and certification health inspection survey process (Form 2567).

Ensures the facility’s plan of correction response to any regulatory, health inspection survey is completed, adequate, implemented and timely.

Serves as the facility representative and spokesperson during health inspection surveys regarding the facility’s QA&A/QAPI program requirement. Presents the QAPI plan and supporting documentation to the State Survey Agency or Federal surveyor at each annual recertification survey and upon request.

Similarly, maintains the QAPI plan and supporting documentation for the Centers for Medicare & Medicaid Services (CMS) upon request.

Leads, guides and directs the facility’s performance improvement project(s) efforts in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents.

Conducts at least one distinct performance improvement project (PIP) annually that focuses on high risk or problem prone areas. Conducts additional projects as needed/assigned. PIP’s may be clinical or non-clinical in nature.

Develops and maintains positive relationships with residents and employees through deliberate positive interactions with them using face to face, phone, or other means of communication to foster positive work relationships.

Facilitates, serves, attends or participates in various committees of the facility as necessary.

Knows and understands general nursing practices and procedures, OBRA regulations, Code of Federal Regulations, Appendix PP State Operations Manual, reimbursement processes, Life Safety Code regulations, applicable labor relations laws, and all other regulatory entities that may apply.

Understands, continues to learn, and teaches others about new CMS program initiatives effecting QA&A/QAPI such as, but not limited to Care Compare, SNF-VBP, SNF-QRP, Quality Measures, etc.

Ensures the facility management/leadership team is focused toward the shared goal of delivering compassionate quality care and services across an interdisciplinary team approach as evidenced by meeting expected outcomes.

Identifies and collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify opportunities for enhanced services to the residents and/or resolve issues.

Conducts rounds, observing residents and staff performance, to further identify care delivery systems in need of improvement and to identify opportunities related to regulatory compliance requirements. Knows residents by name and sight.

Practices management by walking around. Makes himself/herself available to employees at all levels by practicing an open door policy.

Communicates rounding observations to the facility Staff Development Coordinator, Director of Nursing Services and relevant department heads to ensure ongoing educational efforts are aligned with the goals of the QA&A/QAPI program.

Promotes teamwork, mutual respect, and effective communication. Promotes positivity and active daily problem solving.

Leads, guides and directs facility readiness related to health inspection surveys, Occupational Safety and Health Administration (OSHA) surveys, and any other regulatory entity or requirement as assigned by the Administrator/Director of Nursing Services.

Ensures follow up is completed with any “mock” survey issues identified in preparation for health surveys, OSHA surveys, and any other regulatory requirement.

Manages and minimizes facility risk through a team approach to achieve desired outcomes in customer service, key performance indicators and other areas as identified.

Coordinates and cooperates with the facility’s liability insurance carrier and legal representative in the unfortunate event of litigation involving the facility.

Reads and stays informed regarding regulatory requirements and any other changes influencing facility outcomes.

Maintains a reference library of written quality assessment and assurance materials, laws, etc. necessary for complying with current standards and regulations to support the provision of quality resident care.

Engages as a change agent for the facility when necessary.

Serves as chairperson of the facility’s QA&A/QAPI committee(s).

Prepares and plans the QA&A/QAPI department’s budget and submit to the Administrator for his/her review, recommendation and/or approval.

Promotes safe work practices, safety rules, and accident prevention procedures to prevent employee injury and illness.