JOB TITLE: REGISTERED NURSE ASSESSMENT COORDINATOR

JOB CODE: 30425

DEFINITION: This is professional nursing work in healthcare assessment and development of individualized nursing care plans for residents of a veterans’ long-term care facility within the Department of Military and Veterans Affairs.

An employee in this job performs federally mandated healthcare assessments of residents in a veterans’ long-term care facility and formulates individualized nursing plans of care. Work involves performing individualized nursing assessments and reassessments through documentation review, visual observations, discussions with direct care staff, and interviews with residents and family members; coding and recording health care assessment data utilizing a standardized assessment instrument; coordinating and participating with members of the facilities’ interdisciplinary treatment teams to develop comprehensive treatment plans specific to each resident; providing assessment data to state and federal regulators; and monitoring the provision of resident care for adherence to established plans of care. Work may involve the provision of direct nursing care to residents. Work may also involve the supervision of paraprofessional or non-professional nursing direct care staff. Work is performed under the supervision of a nursing manager and is reviewed through reports, conferences, and overall effectiveness of care plans.

EXAMPLES OF WORK: (NOTE: The examples of work are representative of the work, but every position classified to this job may not perform all examples of work listed. Conversely, this is not an all-inclusive list of work examples.)

• Follows the assessment procedures outlined in the Centers for Medicare and Medicaid Services’ (CMS) Resident Assessment Instrument (RAI) to conduct comprehensive healthcare assessments upon admission of residents to a commonwealth-operated veterans’ home/center.

• Utilizes CMS’ Minimum Data Set (MDS) to code and record assessment data gathered from resident healthcare documentation review, visual observations, discussions with direct care staff, and interviews with residents and family members.

• Plans, coordinates, and completes the comprehensive MDS through members of the interdisciplinary treatment teams such as nursing, social services, dietary, activities, and therapy staff.

• Follows the Care Area Assessment (CAA) process to develop comprehensive nursing care plans for treatment of individual long-term care residents based upon collected and coded MDS data in collaboration with interdisciplinary treatment team members.

• Transmits electronic MDS data to CMS and the United States Veterans Administration (VA) as required per federal regulations.

• Reassesses residents as prescribed by federal regulations, including annually and quarterly and due to significant change in status.

• Monitors and evaluates resident care to ensure the appropriate execution of prescribed care plans.

• Communicates with and counsels residents and their families regarding their individual treatment plans as well as health promotion and maintenance.

• Participates in clinical care rounds with other healthcare personnel.

• Administers prescribed medications and treatments and takes physicians’ orders.

• Updates nursing care charts, records, and reports including input into electronic systems.

• Recommends and implements changes in the administration of nursing care and treatment methods and plans.

• Coordinates the development and implementation of residents’ Team Treatment Plans with nursing care staff.

• Provides resident MDS, care plans, and other related information during facility surveys conducted by state and federal regulators such as the Department of Health, Department of Human Services, CMS, and the VA.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the practices, methodologies, and techniques of professional nursing.

• Knowledge of the practices, methodologies, and techniques of patient healthcare assessment.

• Knowledge of regulatory requirements associated with nursing assessments.

• Knowledge of the practices, methodologies, and techniques of the Minimum Data Set (MDS) process as it relates to long-term care patient assessment.

• Knowledge of techniques used to establish, monitor, and evaluate individual nursing care plans.

• Knowledge of the Care Area Assessment (CAA) process as it relates to MDS-based interpretations and decision making in the development of specific nursing plans of care.

• Knowledge of disease and disorder processes and their signs and symptoms.

• Knowledge of the techniques used in the performance of physical examinations.

• Knowledge of therapeutic and adverse effects of pharmacological agents and medical treatments.

• Ability to analyze and interpret laboratory and diagnostic tests.

• Ability to analyze and interpret written information.

• Ability to analyze and interpret numerical information.

• Ability to maintain effective working relationships.

• Ability to communicate effectively orally.

• Ability to communicate effectively in writing.

MINIMUM EXPERIENCE AND TRAINING: (NOTE: Based on the Entry Level Knowledges, Skills, and Abilities)

• One year of clinical nursing experience in a long-term care facility including the performance of MDS-based nursing assessments and the development of individualized nursing care plans;

or

• Possession of an active certification as a Resident Assessment Coordinator – Certified (RAC-CT) as issued by the American Association of Nurse Assessment Coordination (AANAC).

SPECIAL REQUIREMENTS:

• All positions require active authorization to practice as a Registered Nurse in Pennsylvania. • All employees possessing an active temporary practice permit must obtain licensure as a Registered Nurse within the one (1) year period defined by the Pennsylvania State Board of Nursing.