RN / LPN MDS Nurse

Under the direction of the MDS Coordinator, the RN / LPN MDS Assistant is responsible for the timely and accurate completion of the Federal and State assessment tools. This position requires an understanding of the MDS rules and regulations as described in the MDS User’s Manual, including item coding, RAPS, CAA’s, Care Planning, electronic submission, scheduling, PPS including knowledge of MDS submission process, final validation reports, and an understanding of Medicare rules and regulations including coverage, benefit periods, certification, 30 Day rule.

Essential Duties

1. Assists in maintaining Tracking Tools for the MDS and Medicare.

2. Assists in making skilled services decisions and initiates Medicare non-coverage letters and expedited determination notices, as directed.

3. Reviews the health records for each resident, including reviewing written notations of significant changes affecting:

a. Level of activity

b. Eating habits

c. Physical, mental, and emotional status

4. Assists in planning and adjustment of Medicare assessment scheduling.

5. Assists in coordinating the IDT to accomplish timely completion of assignments, Care Plans, and CAA summaries.

6. Assists and teaches, as directed, the Care Planning process to nurses and other members of the team including ADL training.

7. Assists with completing the Medicare Daily Documentation Guide on admission.

8. Assists with studies related to improvements of nursing care, if needed.

9. Assists with gathering baseline information to identify potential and acute problems and thoroughly and accurately completes areas of the MDS nursing admission assessment and quarterly assessment and Medicare assessments using currently approved format.

10. Prepares for and attends team and family Care Plan conferences in a professional, supportive manner, as assigned.

11. Observes and examines the total resident focusing on body systems, skin, integrity, weight, hydration status, and reports changes in resident condition promptly to the Supervisor, as directed.

Standard Requirements

1. Supports the Mission, Values and Vision of the Facility.

2. Is knowledgeable of resident rights and supports an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment.

3. Supports, cooperates with, and implements specific procedures and programs for:

OSHA and safety, including standard precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs.

4. Adheres to:

a. Confidentiality of all data, including resident, employee and operations data.

b. HIPAA regulations

c. Quality Assurance requirements and compliance with regulatory requirements.

d. Compliance with current law and policy to provide a work environment free from sexual harassment and illegal and discriminatory behavior.

e. Code of Conduct and Compliance Programs when performing job functions.

5. Supports and participates in common teamwork:

a. Cooperates and works together with all co-workers; plans and completes job duties with minimal supervisory direction, including appropriate judgment.

b. Uses tactful, appropriate communications in sensitive and emotional situations.

c. Follows up as appropriate with supervisor, co-workers or residents regarding reported complaints, problems and concerns.

d. Promotes positive public relations with residents, family members and guests.

e. Completes requirements for in-service training, acceptable attendance, uniform and dress codes including personal hygiene, and other work duties as assigned.

f. Participates as assigned in the orientation of new staff and demonstrates a positive, helpful, and enthusiastic attitude.

6. Immediately reports incidents of alleged resident abuse or neglect or alleged violations of residents’ rights to Director of Nursing or Executive Director.

7. Knowledgeable of age specific developmental factors specific to adult and geriatric residents (i.e. physical, cognitive and socialization factors) in planning delivery of care.

8. Maintains current practice standards or changes by participating in educational opportunities provided by the Facility and outside resources.

Other Duties

Provides hands on nursing care to residents as needed as a registered professional nurse or licensed practical nurse, consistent with the state’s Nurse Practice Act.

Perform tasks which are supportive in nature to the essential functions of the job, but which may be altered or redesigned depending upon individual circumstances. Performs other work duties as assigned.

Qualifications

Education/Training: Graduate of an approved school of nursing; current nursing license to practice as an RN or LPN in the state. Knowledge of state specific MCD Case Mix, coding guidelines, and State MCD audits, if applicable. Must have current CPR certification.

A.D.A ((Americans with Disabilities Act)(as amended)) REQUIREMENTS: Must be able to bend, stoop, push, pull, and walk and stand for most of the working day. Requires manual dexterity sufficient to provide hands-on care to residents as well as to operate standard office machines such as fax, telephone, etc. Requires normal range of hearing and vision. Must be free from communicable diseases that pose a "direct threat" to the health or safety of others and which cannot be eliminated by a reasonable accommodation. Must be able to lift a minimum of 50 pounds, and transfer and transport residents. Must be able to carry and transport supplies. Must be able to pass a post-offer, pre-employment physical health examination as a condition of employment. Must be capable of performing the essential functions of the job, with or without reasonable accommodation(s).

Skill(s): Proficient reading, writing, grammar, and mathematics skills; proficient interpersonal relations and communicative skills; knowledge of drug interactions, side effects, and incompatibilities; decision-making skill; proficient assessment skills; basic computer skills; able to operate various medical and office equipment; auditory and visual skills. Must be able to communicate in English, both verbally and in writing, and possess sufficient communication skills to perform the tasks required. Experience: A minimum of one year's experience in related nursing positions is preferred.