Care Plan RN

Title: Care Plan RN

ArchCare Program: Ferncliff Nursing Home

Location: Rhinebeck, NY

Overview:

ArchCare cares for people of all ages and faiths where they are most comfortable and best able to receive it – at home, in the community and in nursing homes. As the Continuing Care Community of the Archdiocese of New York, we see enhancing the lives of our elders and others who need extra help to stay healthy and live life to its fullest as more than just a job. To us, it’s a privilege and our calling.

Benefits/Perks:

• Includes accrued vacation days, sick days, and holidays.
• Participation in 403 (b)
• Voluntary Benefits: Short Term Disability, Life Insurance, Cancer Insurance, Pet Insurance
• Discounted membership: Plum Benefits
• Pay for work-related eligible commuter expenses with pre-tax dollars

Responsibilities:

• Responsible for completion of the Admission/Re-Admission; Annual and Significant Change MDS Care Area Assessments (CAAs) and ensures each resident’s comprehensive care plan is person-centered and developed in accordance with State and Federal guidelines. Follows the RAI Manual Chapter 4: CAA Process and Care Planning for standards of care planning.
• As required by 42 CFR 483.21(b), ensures the comprehensive care plan includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
• Ensures all MDS Care Area Assessments (CAAs) are completed by the designated department according to the scheduled dates.
• Development and implementation of the Baseline Care Plan for each resident assigned within 48 hours of admission to include instructions to provide effective and person-centered care that meets professional standards of quality care. Initial goals are based on admission orders, physician orders, dietary orders, therapy services social services and PASARR recommendation if indicated.
• Provides the resident and their representative with a summary of the baseline care plan to include initial resident goals, summary of the resident’s medications and dietary instructions. Maintains records of resident/representative or family receiving the Baseline Care Plan with signature and date.
• Completion of the Initial Comprehensive Care Plan is accurate and includes all clinical care provided; medication classes; ICD 10 Diagnoses Coded on the MDS with goals and interventions.
• Updates the Quarterly MDS Care Plan Goals and Care Plan interventions as indicated in the clinical records; medication classes and new ICD 10 Diagnoses Codes.
• Schedules the Comprehensive Care Plan committee meeting and ensures the residents care plan is developed to include all Care Area Assessments triggered, diagnoses and individualized needs.
• Leads the Care Plan Meetings with the IDT ensuring resident/representatives and families are invited to care plan meetings for the initial admission; readmission; significant change; quarterly and annual care plan meetings in conjunction with the Nurse Manager and Social Worker for units assigned. Ensures Care Plan Meeting notes are entered in the EMR accordingly.
• Attends Weekly UR Meetings for units assigned with the Nurse Manager, Therapy and Social Worker to review coverage and continued stay/discharge plans with all departments. Ensures any recommendations from therapy to nursing for the C.N.A. Assignment is updated in the Care Plan and C.N.A. Assignments for accurate documentation and provision of care.
• Ensures the Care Plans/C.N.A. Assignments are up to date to reflect the current Advance Directives; ADLs; Toileting and special care needs.
• Engages daily with the Nurse Manager of assigned units to work harmoniously on ensuring all documentation is in place and care plans are updated on an ongoing basis to reflect the current and quality of care provided.
• Attends morning meeting daily and reviews the 24-hour report to ensure care plans are revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving (42 CFR 483.21(b), Comprehensive Care Plans).
• Reviews the Provider Matrix and 672 for units assigned to ensure all areas are addressed on the resident care plan. Assists the Nurse Manager with Provider Matrix and the 672 updates and accuracy for NYSDOH Survey Inspections.
• Ensures resident vaccinations are provided and offered in a timely fashion with the Nurse Manager and MDS Nurse.
• Conducts Routine Clinical Rounds daily to assess and ensure documentation noted reflects the care provided.
• Engages on the unit with residents/families and staff daily and assists in resolution of care concerns and care revisions to ensure high level of customer service and quality of care.
• Understands the Quality Measure Criteria and the impact of the Quality Measure on the CMS Five Star Rating Systems for the facility.
• As part of the Nurse Leadership Team, attends meetings with the CNO /CCO and Nurse Managers as indicated to review QM and Documentation System changes and revisions needed to improve efficiency; quality of care and accuracy of MDS Data and care plans.
• Conducts Quality Assurance audits as assigned and submits evaluation of these results in a timely manner.
• As an integral part of the IDT, the assigned workspace will be resident unit based to perform job duties as a Clinical Leader and to act as the main resource for Clinical Documentation/Quality of Care.

Job Type: Full Time

Salary: $48.00 per hour

Education:

• High School Diploma or equivalent. College degree preferred.

Experience Requirements

• Minimum 1 year of MDS experience preferred.

License Requirements

• Current NYS RN license. MDS Certification preferred.