REGISTERED NURSE ROLE AND RESPONSIBILITIES
CLASSIFICATION: Registered Nurse, Adult Foster Care
DATE REVIEWED: September, 2020
REPORTS TO: RN Clinical Manager
REQUIREMENTS/QUALIFICATIONS per AFC Manual:
Qualifications: The Registered Nurse must have
1. Current Licensure by the Massachusetts Board of Registration in Nursing
2. Two years’ recent experience in the direct care of the elderly or disabled adults.
3. Demonstrated leadership ability
4. Commitment to quality care, and the multidisciplinary team approach
5. Competence in CPR and First Aid
6. CORI, Physical in the past 12 months, and Annual TB Test
SUMMARY OF RESPONSIBILITY:
The Registered Nurse is accountable for the practice of professional nursing, delivering quality care through the application of the nursing process. The RN provides the essential level of professional nursing needed by each member, and works with management staff, and other personnel and volunteers to ensure quality of care at all times.
1. Provide and/or supervise basic and skilled nursing services for each member
2. Supervise other healthcare staff, including ongoing training for caregivers
3. Coordination, development, and on-going review of Care Plans
4. Monitoring of all members to ensure the effectiveness of AFC service
5. Review and implement physician orders, including semi-annual and annual physician reviews
6. On-site visits for admission, significant change, and monthly or bi-monthly as required
7. Assure nurses’ notes are written at least monthly, and address significant changes in member conditions
- Frequent commuting in automobile up to 95%
- Must have reliable transportation at all times
- Registered Nurse must be able to serve and/or take on additional members when there is a staffing shortage, or another Registered Nurse is out on a leave.
- Free standing patient environment with exposure to clinical equipment/machinery, medications, cluttered rooms and hallways, noisy environment with frequent interruptions.
- Exposure to infectious illness, body fluids and cleaning materials.
- Office and technical equipment such as computers, fax machines and copy machines.
DAILY/SPECIFIC ROLE REQUIREMENTS:
MDS (Minimum Data Set): is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified Adult Foster Care programs. This process provides a comprehensive assessment of each resident’s functional capabilities and helps Caregivers identify health problems.
● RN is alerted when a member is ready for an MDS. RN will receive electronic copies of medical documentation (PSF, Summary of Last Office visit, Medications sheet, Referral Sheet and TB/Medical Form for both Member and Caregiver). RN is responsible for reviewing medical documentation prior to going out to complete MDS.
● If all health information for the Member is not found in member file folder, RN is to notify the membership coordinator or designated staff member via email and provide the member’s full name for research and resolution.
● RN is responsible to contact the Caregiver/Member at their residence to schedule an appointment within 24 hours of notice from WeCare 365 for an in-home visit to complete the Minimum Data Set (MDS).
● RN will update their WeCare 365 Shared Calendar to reflect all MDS appointments. Include: your name or initials, Member Name, Type of Appointment (MDS, Contract Signing, Monthly, Semi-Annual, Annual).
● If RN cannot reach Caregiver/Member to schedule appointment within 24 hours of notification of MDS readiness, RN must send notice of this to the membership coordinator or designated staff member via email so that this can be assessed.
● If WeCare 365 Management does not see scheduling for an MDS assigned to you within the 24-hour window, and there has been no reason noted in the escalation email box, the MDS will be scheduled for you based on what is viewed in your shared calendar.
● RN will be notified of any MDS meetings scheduled for you via email and phone call.
● It will be the RN’s responsibility to attend and be prepared for any scheduled MDS meeting in accordance with their employment contract with WeCare 365.
● RN is responsible to stress to the Member/Caregiver that scheduling and completing the MDS as soon as possible is of utmost importance in the process to become an AFC member
● RN is responsible for making sure they are knowledgeable in Level Qualifying each Member as well as all sections of the MDS documentation.
DURING MDS APPOINTMENT
● RN will review all sections of the MDS documentation with Member/Caregiver/Alternate Caregiver, for understanding, signatures and for completeness and accuracy.
POST MDS APPOINTMENT
● RN is responsible for making sure all items on the MDS documentation are filled in completely and correctly (including, but not limited to Date of Birth and Date Case Opened).
● RN will also provide an MDS Narrative along with the MDS form for submittal to the member file.
● RN will also provide a completed and correct Request for Services document as required with the MDS Narrative and MDS.
● CM assigned to the Member/Caregiver will reach out to RN for information from the MDS which may include requesting a copy of the MDS Narrative as well as the Level Determination, to better prepare for the Member/Caregiver Contract Signing.
● RN is responsible for review and update of member MDS annually as well as submitting this MDS to the member file.
POST MDS COMPLETION:
· RN is responsible for attending Caregiver/Member Contract Signings for Level I and Level II Members and coordinating this home visit with Care Manager.
· RN will submit an encounter Progress Note as part of this visit.
Member Plan of Care
· RN as part of the Nursing Oversight will develop, discuss, sign and submit the members interim (5-day) CarePlan using the Contract Signing date as Day 1. This Interim Plan of Care will be discussed with the Member and Caregiver and made available to the member file and assigned Care Manger. A final (30 day) Comprehensive AFC plan of care, with input from the Member, the Caregiver, the Care Manager and all members of the MDT and other individuals designated by the member. This Comprehensive Care Plan shall be presented, discussed and signed by RN, CM, Caregiver and Member before being submitted to the member file.
· RN will review the AFC plan of care annually or as necessary if member conditions change.
● RN responsible for working with CM on scheduling Level I or Level II visits based on AFC regulations.
● RN responsible for updating their shared calendars with these level-based appointments. Include your name or initials, Member Name, Type of Appointment (MDS, Contract Signing, Monthly, Semi-Annual, Annual).
● RN responsible for updating WeCare 365 management if caregiver/member are not agreeing to, or available for, scheduled visits via escalation email box.
● RN responsible for checking in with caregiver/member regularly regarding any type of Leave Of Absence, completing requisite Leave Documents, and notifying WeCare 365 management of this information via leaves email box.
● RN responsible for training, evaluating and supervising Caregivers during these visits in conjunction with the Care Manager.
● RN responsible for conducting an Orientation for each Caregiver before the Caregiver begins personal care.
● RN responsible for monitoring the health status of all their assigned members to ensure that all needed AFC is properly delivered.
● RN responsible to create and complete a New MDS upon significant’ change in status with the medical documentation to support the change.
● RN is to report any changes to the Member’s Physician and WeCare 365, and note that proper documentation is submitted.
● RN responsible for completing a Nursing Progress Note corresponding with each on-site visit or encounter, or more often as the member’s condition warrants.
● RN responsible to submit a Plan of Care with the Semi-Annual and Annual health-status report to the WeCare 365 Database Administrator, who will fax to member’s Primary Care Physician.
● RN responsible for planning for and implementing Discharges from the AFC program, and this Discharge Plan should be completed with a Plan of Care as necessary and required. This Discharge Documentation should be properly signed and submitted to the WeCare 365 offices for filing.
● RN when necessary and appropriate, shall be responsible for supporting WeCare 365 and the AFC program by reinforcing the consequences for infractions to the contract that the Caregiver has signed to provide care to the Member. Examples of this infraction may include: missing appointments, non-supervision of Member outside of specified time frames.
● RN needs to be able to discuss the requirements of the program and WeCare 365 AFC’s ability to provide a stipend are mandated by the State of Massachusetts not WeCare 365.
Semi-Annual Health Status and Annual Health Status Reports
· RN responsible for conducting a semi-annual health status report which is faxed to member PCP for signature. Copies of Fax Cover Sheet and report to be kept in the member file.
· RN responsible for conducting an annual health status report which is faxed to member PCP for signature. Copies of Fax Cover Sheet and report to be kept in the member file.
· Annually RN must Complete an Optum PCP Form for each member to be sent along to the members Primary Care Physician for review and approval.
If you are unable to make a scheduled appointment
● If you will be unable to attend your scheduled appointment with Caregiver/Member/Alternate Caregiver for any reason, you must make every effort to call your direct manager immediately. In these instances, manager will make arrangements to reach out to Caregiver to discuss the situation and let them know what will be done, i.e., reschedule or sending another RN.
● You will be notified of the course of action by your direct manager or program director via email.
● When able, updates to your shared calendar will need to be made to reflect the changes made to the appointments you have missed. Please include any information you receive on rescheduled appointments or replacement of registered nurse for the appointment.
WeCare Outlook Email
● RN responsible for checking their WeCare 365 Outlook Email each day and acknowledge that they have received it, either by sending Read Receipt or by Liking the email.
WeCare Business Cell Phone
- RN responsible for checking their WeCare 365 Business Cell Phone frequently each business day and returning all calls within 2 – 4 hours during regular business hours.
- RN will have their phones on during on-call hours assigned.
Case Files – Chart Review
● RN responsible for checking each of their Case Files via 4D Database regularly as a Chart Review for completion and compliance.
● Are there documents missing from the file (PSF, MDS, Logs, etc.)
● Are all documents that need signatures signed?
● Is everything set for the month in your Case Files?
● Monthly reports will be sent to your attention from compliance department that must be reviewed, and tasks completed as necessary and, in a time-sensitive manner. Direct manager will have full discretion to set up mandatory meeting time to address compliance concerns.
Monthly Staff Meetings and Training
● RN is responsible to attend WeCare 365 Monthly Meetings held at the Brockton or Framingham office site. If Part Time or Per Diem, RN is responsible for accessing audible monthly meeting file and reviewing materials.
● RN is responsible to attend WeCare 365 Monthly Trainings held at the Brockton or Framingham office site. If Part Time or Per Diem, RN is responsible for accessing audible monthly training file and reviewing materials.
** Roles and Responsibilities subject to change, staff will be notified if changes in their role occur and review and signatures will be initiated on all changes.
Registered Nurse ROLE AND RESPONSIBILITIES document has been presented to, read, understood, and is attested to by:
Registered Nurse: ___________________________________________________________