SUMMARY: The MDS Assistant / Restorative Nurse is responsible for the accurate and timely completion of all Medicare/Medicaid case-mix documents in order to assure appropriate reimbursement for care and services provided within the Facility. Conducts continual Minimum Data Set (MDS) reviews to assure achievement of optimal allowable Resource Utilization Group (RUG) category. Oversees the overall process and tracking of MDS/Prospective Payment System (PPS) documentation and submission. He/she will integrate nursing, dietary, social recreation, restorative, rehabilitation and physician services to ensure appropriate assessment and reimbursement. In addition, the incumbent is responsible for the development, implementation, monitoring and supervision of the restorative nursing program for the facility, acting as the liaison between formalized therapy and nursing. They promote a restorative nursing philosophy among facility departments.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Assesses and determines the health status and level of care of all new admissions.
• Ensures the accurate and timely completion of all MDS Assessments including PPS Medicare, quarterly, annual, significant change.
• Communicates level of care for new resident to all disciplines.
• Coordinates interdisciplinary participation in completing the Minimum Data Set (MDS) for each new admission to facility according to regulatory time frames. Ensures completeness and thoroughness of documentation as mandated by federal, state and medical standards.
• Maintains an accurate schedule of all MDS assessments to include the proper reference dates throughout the resident’s stay.
• Responsible for the data entry function to assure accurate data entry and electronic submission of MDS assessments.
• Verifies electronic submissions of MDS, performs corrections when necessary and maintains appropriate records.
• Coordinates interdisciplinary participation in completing the MDS for each resident according to regulatory time frames. Ensures completeness and thoroughness of documentation as mandated by federal and state standards.
• Schedules and conducts resident care conferences in compliance with state and federal regulations and ensures completion of all MDS reviews prior to resident care conference.
• Assists disciplines in formulating and revising care plans. Ensures that resident’s present/potential problems are identified and prioritized; realistic goals are established and nursing intervention is appropriate.
• Evaluates resident care plans for comprehensiveness and individuality.
• Assesses the achievement or lack of achievement of desired outcomes. Ensures that resident’s care plan is reassessed and revised appropriately.
• Responsible for all level of care changes within the facility. Notifies all departments when a level of care change has been made.
• Generates appropriate forms to complete level of acuity and changes. Transmits forms to the appropriate agency for processing as required by state law.
• Assists and participates in the development, organization and implementation of the philosophy, objectives, policies, procedures and standards of nursing care in accordance with the goals of the Care Center Facility care and the individual center.
• Confers with the Director of Nursing/Assistant Director of Nursing in assessing the quality of nursing care being delivered and recognizes the need of improving or changing nursing practices.
• Makes daily rounds to evaluate patient care, the progress of individual employees, monitor nursing practices, and assist Human Resources with nursing and educational needs.
• Remains cognizant of legal aspects of nursing practice, as well as government regulations; demonstrates this in teaching, supervision, and evaluation of patient care.
• Performs rehabilitation assessments upon all new admission and for existing patients throughout the center on quarterly basis and as needed.
• Performs or oversees functional evaluations on admission, quarterly and/or as clinically indicated. Consults with nurses in making recommendations for restorative plan of care. Works with nurses in developing restorative plan of care.
• Oversees that all restorative nursing measures are reflected on the care plan as an approach to the focus or need for which that are being completed.
• Works closely with the therapy department. Sees that specific recommendations, when discharged from therapy are carried through.
• Reviews weekly documentation completed for residents receiving restorative services. Ensures that all proper ADL documentation has been completed for patients.
• Oversees incontinent management programs.
• Attends care planning conferences and makes recommendations. Reports progress of restorative nursing measures.
• Attends Interdisciplinary/QAPI meeting as indicated to provide feedback and identify any residents for evaluation of restorative service needs.
• Coordinates with Human Resources and Director of Nursing to orient new staff relative to roles, responsibilities, principles and practices of restorative nursing.
• Coordinates with Director of Nursing and Therapy to provide ongoing education/evaluation of direct care staff relative to roles, responsibilities, principles and practices of restorative nursing.
• Actively participates in physical restraint reduction and fall management programs.
• Sets up documentation flow sheets for daily documentation of restorative nursing measures for each resident on the program in coordination with medical records.
• Performs or supervises the performance of restorative nursing staff.
• Serves as a liaison with all therapists: physical, occupational, and speech.
• Participates in patient care planning and CMI meetings.
• Serve in the role of Medicare Services Coordinator (MDS Coordinator) as needed.
• Puts patients first; ensures that patients and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals’ needs and rights
• Other duties as assigned.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill, and/or ability required.

• Registered Nurse with current unencumbered state license.
• The incumbent should possess 3 – 5 years of equivalent clinical experience.
• Current CPR certification is required.
• Long Term Care Experience preferred.
• Ability to read, write, speak and understand the English language.

PHYSICAL DEMANDS: The physical demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Required to sit, stand, bend and walk regularly; lift and/or move up to 25 pounds.
• Visual and auditory ability sufficient for written and verbal communication.
• The noise level in the work environment is usually moderate.