Job Description
> Keep MDS schedules for completion date, and care conference date; deliver this information to all staff involved with MDS and care planning.
> Open MDS records per the ARD.
> Complete MDS sections and CAA’s completed by Nursing; close all MDS records after completion.
> Set assessment dates for all non-skilled residents.
> Complete care plans per Federal regulations and with any changes.
> Provide a calendar with ARD set for all OBRA assessments to the interdisciplinary team and the units.
> Attend morning clinical meetings, complete Utilization review minutes in PCC and attend the weekly utilization review meetings.
> Create all discharge and re-entry tracking forms.
> Assist with new admissions, as needed.
> On a monthly basis, randomly review ADLs for accuracy
> Complete required documentation, including resident evaluations, Medicare documentation, care plan entries, daily progress notes, and weekly summaries before the end of shift.
> Ensure that MDS, assessments, care plans, nursing documentation, and transcribed orders are complete, accurate, and conform to regulatory requirements for compliance.
> Conduct routine chart audits when completing the MDS to ensure that medical record documentation is in compliance with State and Federal guidelines.
Requirements
Education and Experience
> Graduation from an accredited school of nursing.
> Five (5) years experience as a nurse and two (2) years of leadership experience or a willingness to learn and apply principles of leadership.
> Be knowledgeable about and experienced working with the Minimum Data Set Assessment, PPS and management of assessment reference dates, and State and Federal guidelines related to long-term care.
> Maintain a current comprehensive knowledge of nursing theory and practice.
> Knowledge of Point Click Care electronic health record.
Professional Licenses or Certifications Required by Law
> Current licensure as a Registered Nurse in the State of Montana
> Current CPR certification; up-to-date knowledge of First Aid
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Immanuel Lutheran Communities