The purpose of this position is to assess residents' physical and mental function and document data on minimum data set forms completely and accurately; document all additional assessments required completely and accurately; and determine appropriate referrals to other health care professionals; and to use the resident assessment protocols to determine whether to proceed or not proceed.

Functions:

• Interview residents, residents' representatives and others with information related to the minimum data set assessment.
• Collect all data necessary to complete minimum data set forms and related documentation.
• Coordinate Quality Assurance meetings.
• Participate and/or conduct interdisciplinary meetings.
• Review medical records and records related to residents' health status to collect information related to the minimum data set assessment.
• Enter data into the computer program for minimum data set assessments.
• Assume accountability and responsibility for accuracy of Minimum Data Set (MDS) assessment information.
• Every Friday post lab for coming week.
• Comply with all federal and state regulations when completing the Minimum Data Set assessment.
• Comply with all facility policies and procedures when completing the Minimum Data Set assessment.
• Schedule Minimum Data Set assessments to comply with federal and state regulations and facility policy.
• Receive and file all diagnostic reports promptly and accurately.
• Electronically transmit Minimum Data Set assessments in compliance with federal and state regulations.
• Print Minimum Data Set assessments and related reports from the computer program.
• Coordinate weekly care plan meetings for Director of Nursing.
• Coordinate scheduling with Director of Nursing to assure compliance with State regs.
• Conduct and/or participate in interdisciplinary team and rehabilitation conference meetings.
• Complete reports and assignments accurately and adhere to established time schedules.
• Maintain confidentiality of resident and facility information.
• Establish open lines of communication between all nursing personnel.
• Observe infection control procedures relating to nursing services.
• Observe Residents' Rights policies at all times.
• Observe all facility safety policies and procedures.
• Come to work as scheduled and consistently demonstrate dependability and punctuality.
• Consistently work cooperatively with administration, nursing service personnel, physicians, community agencies, residents, families and consultants.
• Come to work in a clean, neat uniform and consistently present a professional appearance.
• Assume accountability for data contained in the employees' handbook.
• Perform other duties as directed by the Director of Nursing.
• Perform all duties assigned in a cooperative, effective, timely and professional manner.
• Be responsible for the safety of residents under his/her supervision.
• Orient all new employees (all departments).
• Complete paperwork for new employees on day of orientation and turn in to Administration.
• Assist with admission, transfer, and discharge of residents as assigned by the Director of Nursing.
• Develop monthly calendar of duties for Director of Nursing.
• Protect all medical record information from loss, defacing or destruction before retention period ends.
• File medical records promptly and accurately.
• Retrieve medical records promptly upon request by authorized individuals and agencies.
• Identify late and incomplete documentation and report to individuals responsible for completion.
• Identify inaccurate documentation and report to individuals responsible for accuracy and documentation.
• Audit medical records, as assigned.
• Collect and accurately process telephone orders daily.
• Complete identification on forms in residents' medical records.
• Assemble admission packets.
• Process admission and discharge records timely and accurately.
• Complete all information on admission records and place in medical record holder following facility policy and procedure.
• Assist the Administrator and Director of Nursing to coordinate all required committee and meeting functions.
• Enter physician orders and other information into the computer timely, accurately and completely.
• Print forms and reports from the computer program as required.
• Audit transfer/discharge information for accuracy and completeness.
• Gather information for Medicare billing and complete by 2nd work day of each month.
• Order medical supplies and nursing equipment as required by Director of Nursing.
• Ensure Medicare residents have timely certification/re-certification forms signed by the attending physician.
• Be responsible for ordering supplies monthly.
• Maintain supplies in a neat, clean and organized manner.
• Receive, review and have requisitions approved before ordering.
• Receive or unload supplies and distribute, stock and/or store in a neat, efficient and safe manner.
• Report any problems with ordering or obtaining supplies to the Director of Nursing.
• Provide accurate reports to D.O.N. of the type and amount of supplies received.

Qualifications:

• Must be familiar with Long Term Care state and federal rules and regs
• Must be knowledgeable in computers (Outlook or Outlook Express, Internet Explorer, Microsoft Office, Microsoft Windows XP)
• Must be able to lift, stoop, bend, squat, etc. without restrictions
• Must be familiar with Quality Assurance
• Must be familiar with Infection Control

Education:

• High school diploma

Certification:

• Must have current CMA license

Continuing Education:

• As required by state and facility, including seminars.

Schedule:

• Monday - Friday