The Care Plan Coordinator is responsible for the timely and accurate completion of the MDS, assessment protocols, comprehensive assessment and the development of each resident's individual Plan of Care.

He / she solicits information from an interdisciplinary team (including the resident and the resident's family), develops the care plan, informs the staff and implements the completed Plan of Care.

He / she monitors and records the progress (or lack of progress) of each resident. The CPC observes resident care on a daily basis to ensure the implementation of the Plan of Care.

Responsibilities

Administrative Functions

• Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment, including the implementation of RAPs and Triggers.
• Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc.

that are necessary for providing quality care.

• Maintain and periodically update written policies and procedures that govern the development, use, and implementation of the resident assessment (MDS) and care plan.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, etc., as necessary.
• Develop, implement, and maintain an ongoing quality improvement program for the resident assessment / care plans.
• Must be knowledgeable of nursing and medical practices and procedures, as well as, laws, regulations, and guidelines that pertain to long-term care.

Committee Functions

• Act as Chairperson of the Interdisciplinary Care Plan Team.
• Work with the Interdisciplinary Care Plan Team in developing a comprehensive resident assessment and care plan for each resident.
• Serve on, participate in, and attend various other committees of the facility as required, and as appointed by the Administrator.
• Provide written and / or oral reports of the resident assessment / care plan functions as requested or directed.

Personnel Functions

• Must possess leadership and supervisory ability and the willingness to work harmoniously with professional and non-professional personnel.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies / personnel and the general public.
• Maintain an effective, friendly working relationship with health professionals, physician, consultants, and governmental agencies that may be involved in the resident assessment / care plan functions of the facility.
• Meet with and solicit advice from department personnel concerning the resident assessment t / care plan functions of the facility.

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.
• Schedule the resident assessment / care plan meetings and provide scheduled dates to team members
• Contact and assist in scheduling participation by outside members of the care plan team, including the resident's representative and / or other interested family members.
• Work with staff to ensure that care is provided in accordance with the resident's wishes.

Staff Development

• Assist in training activities needed concerning resident assessment / care plan skills.
• Attend and participate in annual OSHA and CDC in-service training programs for hazard communication, TB management, and bloodbome pathogens standard.
• Attend and participate in continuing education programs designed to help you keep abreast of changes in this profession, as well as to maintain your license on a current status.

Care Plan and Assessment Function

• 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.
• Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions.
• Coordinate the development of a written plan of care 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, and mental psychosocial needs as identified in the resident’s assessment.
• Ensure that the initial, quarterly, significant change and annual resident assessments and are completed within required time frames.

Resident Rights

• Maintain the confidentiality of all resident care information.
• Ensure that resident interviews are conducted in private.

Required Skills

• Be of legal working age
• Be able to read and follow written directions
• Be able to communicate with residents and co-workers in English
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies / personnel and the general public.
• Work overtime is necessary
• Current license in good standing in the state in which the facility is located as a Licensed Practical Nurse or Registered Nurse
• Must have a working knowledge of medical, pharmaceutical, psychological and social treatment, care and terminology.
• This position requires general knowledge of physical, mental and psychosocial well-being in the elderly and the ability to integrate this information to develop an interdisciplinary Plan of Care.

Last updated : 2024-03-31