MDS/Care Coordinator

Key Responsibilities/Duties

Administrative Functions:

 • Maintain and periodically update written policies and procedures that govern the development, use and implementation of the resident assessment (MDS) and care plan.

 • Perform administrative duties such as completing medical forms, reports, evaluations, studies, etc. as necessary.

• Develop, implement and maintain an ongoing quality assurance program for the resident assessment/care plans.

• Monitor the facility’s QI and QM reports to ensure that appropriate corrective action can be implemented when potential problem areas occur.

• Ensure that all assessments are completed and transmitted in a timely manner. Report problem areas to the Director of Nursing and Administrator accordingly.

Care Plan and Assessment Functions:

 • Develop preliminary and comprehensive assessments of the nursing needs of each resident, utilizing the forms required by current rules or regulations and facility policies.

• Ensure that appropriate health professionals are involved in the assessment.

• Works with the Interdisciplinary Care Plan Team in developing a comprehensive resident assessment and care plan for each resident.

• Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions and that they are aware of the policies, including civil money penalties, for false certification.

• Coordinate the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished and which professional service is responsible for each element of care

. • Ensure that the care plan includes measurable objectives and timetables to meet the resident’s medical, nursing, mental and psychosocial needs as identified in the resident’s assessment.

 • Ensure that an initial resident assessment and base/ME is completed within three days of the resident’s care plan admission.

• Ensure that a comprehensive care plan is completed within twenty-on days of the resident’s admission.

• Assist the nursing staff in encouraging the resident and his/her family to participate in the development and review of the resident’s plan of care.

• Assist the Director of Nursing and relevant directors/supervisors of other departments in ensuring that all personnel involved in providing care to the resident are aware of the resident’s care plan and that nursing personnel refer to the resident’s care plan prior to administering daily care to the resident.

 • Ensure that quarterly and annual resident assessments and care plan reviews are made on a timely basis.

• Ensure that a complete resident assessment is conducted within fourteen days of a significant change in the resident’s condition.

 • Coordinate the review and revision of the resident’s care plan by the interdisciplinary team after each quarterly review or other assessment, assuring that the care plan is evaluated and revised each time an assessment is done when there is a change in the resident’s status.

 • Assist the Director of Nursing and other relevant directors and supervisors in maintaining good rapport and morale between and within departments to ensure that a team effort is achieved in developing and implementing a comprehensive assessment and plan of care.

• Inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS).

• Ensure that each portion of the assessment is signed and dated by the person completing that portion of the MDS.

• Sign and date the assessment instrument to certify its completion.

• Ensure that medical and nursing care is administered in accordance with the residents’ wishes, including the implementation of advanced directives.

Supervisory/Staff Development Functions:

• Maintains an effective, friendly working relationship with health professionals, physicians, consultants, Brewster Place employees and governmental agencies that may be involved in the resident assessment/care plan functions of the facility.

• Meet with and solicit advice from department supervisors concerning the resident assessment/care plan functions of the facility.

 • Develop and participate in the planning, conducting and scheduling of timely in-service training classes that include assessment skills or techniques needed to complete the assessment functions of the facility.

• Conduct training programs for appropriate staff on the completion and use of the MDS.

Nursing Care Functions:

• Conduct or coordinate the interviewing of each resident for the resident’s assessment.

• Evaluate each resident’s condition and pertinent medical data to determine any need for special assessment activities or a need to amend the admission assessment.

• Develop and implement procedures with the Director of Nursing to inform all assessment team members of the arrival of newly admitted residents.

 • Assist the Director of Social Services in scheduling the resident assessment/care plan meetings as necessary. Contacting and scheduling participation by outside members of the care plan team, including the resident’s representative and/or other interested family members.

 • Ensure that care provided is in accordance with the residents’ wishes.

 • Participates in the Nurse Manager on call schedule.

The most significant duties have been included in this description.  This does not preclude the assignment of occasional additional or developmental duties.  The organization reserves the right to modify this job description as needed to accurately reflect duties assigned.