Director of Quality and Infection Prevention (QAPI/MDS), RN

Tabitha at Prairie Commons in Grand Island, NE is seeking a full time Quality and Infection Prevention Director/MDS RN. The QIP Director would oversee all quality and infection prevention programs to ensure consistency within established policies and regulatory direction to improve the quality of care provided to residents in accordance with Eventides Mission and Vision. Maintains communications and cooperates with facility leadership, Medical Director, and Corporate Office to implement current quality program and documents activities related to the Quality Program. Responsible for Infection Prevention at the facility, including employee health and the risk management activities. This position will also assist with MDS Coordination by organizing and completing documentation requirements in the nursing department in accordance with current federal, state, and facility standards, guidelines, and regulations. Routinely contacts staff, families, other department directors/coordinators, and physicians as needed.

ESSENTIAL FUNCTIONS:

• Implements quality activities and programs to enhance resident services. Utilize on-going evaluation to measure success and influence quality improvement.


• Collect and analyze data.


• Develop reports and recommendations for process improvement to enhance resident care and services utilizing appropriate methodologies such as Root Cause Analysis, Rapid Cycle, and Lean and understands when each is appropriate to the situation.


• Reviews/changes the facility QAPI Improvement and management plan to meet existing standards, Board approved quality plan and sends to the corporate office for final approval.


• Manages the infection control function for the entire facility.


• Provides formal and informal Infection Prevention education to support the delivery of excellent care to residents and staff.


• Performs infection surveillance and collects data on residents with infections to ensure that infections are monitored for organism, transmission and antibiotic appropriateness.


• Appropriately identifies trends in outbreaks and reports to the state after discussion with the Medical Director and campus Executive Director.


• Coordinates and administers the immunization program for all new and existing employees which is in-line with state and federal regulation, including influenza and Hepatitis B. Performs and enforces TB testing according to regulation and annual TB screening of employees.


• Performs audits on a regular basis to ensure compliance with federal and state regulation regarding infection prevention (ie. Handwashing, isolation, cultures, and antibiotic usage).


• Actively participates and prepares reports for the state as requested by maintaining a current and active infection prevention program utilizing appropriate software


• Monitors employee illness for trends in relationship to resident illness and puts in place action which diminishes the impact and safeguards both groups.


• Plans, implements and evaluates educational needs of all employees.


• Prepares, conducts and coordinates training programs for all employees and management.


• Serves as the Minimum Data Set (MDS) Coordinator for the campus, functioning to coordinate and complete the entire MDS process, working with other departments as needed.


• Assesses residents' health status needs through physical assessments, observation, and interview, and documents findings accordingly.


• Provides and monitors accurate documentation in the resident record according to established nursing policies, procedures, and standards. Acts as a resource for accurate and complete documentation to include Medicare and case mix classifications.


• Completes, monitors, and evaluates residents' plans of care, making appropriate changes in plans of care, whenever necessary. Ensure that plans of care are complete and comprehensive.


• Schedule Mandatory In-services.


• Assist Human Resources with New Orientation and implementation.


• Maintains a positive working relationship with all staff.


• Displays friendly, outgoing, helpful attitude toward all employees.


• Recommends new approaches, policies and procedures to effect continual improvements in efficiency of department and services offered.


• Maintains compliance with company policies and federal and state regulations concerning employment.


• Will rotate weekend and weekly on call responsibilities and provide leadership to direct care staff.

EDUCATION AND EXPERIENCE:

• Successful completion of an approved Registered Nurse education program required


• Current Certificate in CPR/BLS is required


• CPR Instructor certification is required, may be obtained after hire


• Experience in Long Term Care is preferred


• Minimum Data Set experience preferred

CERTIFICATES, LICENSES OR REGISTRATIONS:

• Must have a NE RN License.


• Must currently be in good standing in all states in which you have ever been license as a nurse in the U.S.


• Current CPR (or approved equivalent) certification

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