****MON-FRI Day Shift****
 

This position is a combination of Infection Control and Quality Assurance.  LPN and RN are welcome to apply.

Duties/Responsibilities:

• Develop, implement, and evaluate the organizational infection prevention program to include policies and procedures for surveillance, pandemic preparedness, hand hygiene, standard precautions, employee and resident infection control education, employee health, outbreak management, and transmission-based precautions according to Federal/State/Regulatory Agency guidelines.

• Educate residents and employees about proper hygiene techniques and encouraging them to practice good health habits including, but not limited to:
  • Hand hygiene
  • Cleaning, disinfection, and sterilization 
  • Specific direct and indirect care settings 
  • Therapeutic and diagnostic procedures and devices
  • Use of isolation/barrier precautions when indicated
  • Placement, transfer, and discharge of residents with communicable disease or infections
  • Environmental hazards
  • Use of patient care products and medical equipment
  • Resident immunization programs
• Coordinate resident care with other members of the healthcare team, including physicians, pharmacists, lab technicians, and social workers, to ensure that patients receive appropriate treatment and follow up care.
• Enforce policies and procedures prohibiting staff with communicable diseases or infected skin lesions from direct contact with residents and their food, and enforce hand hygiene policies consistent with accepted standards of practices
• Develop an annual surveillance plan based on the population(s) served, services provided, and analysis of surveillance data.
• Evaluate and modify the surveillance plan and infection prevention policies and procedures no less than annually and as needed.
• Interacts with physicians, nurses, department managers, supervisors, and occupational health and other professional/non-professional staff members to provide resource information, resolve infection control problems, and identify new opportunities to improve service and reduce costs.
• Serve as a member of the Quality Assurance Committee and Board Quality Committee.
• Directs and assists in preparing reports and statistical data for nursing and QA meetings and for nursing/executive team/Board review as needed.
• Comply with regulatory and mandatory reporting requirements at the local, state and federal levels.
•  Maintain current knowledge with CMS, and MDOH regulatory agencies and CDC public health guidelines as it relates to infection prevention
• Routinely audit current facility practices for any deficiencies or lack of care
• Assist the Director of Maintenance and EVS Supervisor with the coordination of Infection Control procedures for handling of soiled laundry/linen, equipment and cleaning. 
• Participate in any Facility Survey by any regulatory agency.
• Report any and all reportable diseases or infections to the County and State Health Departments and maintain a correct line listing for any Outbreak. 
• Coordinates and chairs the monthly and quarterly Quality Assurance meetings.  Record meeting minutes accordingly and assure the ombudsman, resident, and family council receive a copy of the minutes.
• Participates in the monthly and quarterly Quality Indicator/ Quality Measures meetings.  Complete assigned quality indicator reviews.
• Participates in the Fall and Hydration Committee by analyzing trends and patterns and creating an action plan as needed.
• Completes the transcription, lab, routine lab, Coumadin, QA chart, and weight audits monthly.  Completes Diabetic Audits quarterly.  May delegate audits accordingly.
• Coordinates and assures a Bladder Program is established for every resident that would benefit from the program.  Complete an initial Toilet/Bladder Assessment for all residents to assess their bladder function and assure needs are met.  Another bladder assessment will be completed yearly and if the resident has a change in bladder habits to assure a program is implemented.
• Track and analyze medication errors and clinical incidents.  Assure appropriate follow up and discipline is completed.   Create a threshold for each individual and discipline as needed with DON or ADON.
• Assure all residents with a restraint have a yearly consent signed by their family and have progress notes signed by the PCP every 3 months. The goal is to have the least restrictive device and to be as restraint free as possible.
• Complete psychotropic logs monthly and complete semi-annual DISCUS and Obra forms from residents on anti-psychotics. Monitor for EPS symptoms and follow-up with physician if indicated. The goal is to reduce therapy at least every 3 months, if not; a progress note is to be completed with a physician evaluation.
• Track all medicines that require lab drug levels to be drawn monthly.  Complete a lab audit monthly to assure all abnormal drug levels had the appropriate interventions implemented.
• Track IVs, Foleys (Assure each resident has a diagnosis and progress note from the urologist or PCP), Hospice, Care and Comfort, Oxygen, Diabetics, and residents with feeding tubes monthly. Analyze the data and action plan any trend or pattern identified, this includes root cause analysis if needed.
• Complete mortality/morbidity reviews on each deceased resident to determine unexpected vs. expected death.  If unexpected, have the Medical Director complete the Medical Director Review From for unexpected deaths with interventions as deemed necessary.
• Complete unplanned transfers for residents that are transported to the hospital, etc… unexpectedly to determine avoidable vs. unavoidable status.  Log all unplanned transfers on unplanned transfer log. If the transfer is considered avoidable, education/disciplinary process is indicated.
• Performs other administrative duties as required such as completing medical forms, reports, audits, as necessary.
• Collaborates and provides advisement to all departments regarding associate educational/training needs.
• Conducts quality assurance projects as they relate to survey readiness-
  1. Dining experience audits
  2. Call bell audits
  3. Safety checks/hazard checks
  4. Pharmacy medication reviews
  5. Change in condition audits
  6. Kardex audits
  7. GNA peri-care audits
  8. Assures housekeeping, maintenance, and dietary completes audits for resident safety. Analyzes data and action plans as needed    
• Advises the DON/ADON regarding potential resident care or life problems.
• Participates in the monthly safety committee.
• Participate and coordinate pain management committee.
• Complete action plans as needed.  Assign duties to appropriate staff and ensure follow up.
• Coordinate a Root Cause Analysis Program for sentinel events.
• Complete and update policies and procedures as needed.
• Complete all other assigned audits as scheduled. 
• Infection control: Plans and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment. Ensures all infection control activities are completed by Federal and State standards with follow up on any suspected outbreaks with appropriate measures taken.
  1. Analyze and interpret infection control data
  2. Investigate and survey suspected outbreaks of infection
  3. Plan, implement, and evaluate infection prevention and control measures
• Provides managerial oversight of all infection control activities including policy setting, education, and prevention/control activities.
  1. Educate individuals about infection risk, prevention, and control
  2. Develop and revise infection control policies and procedures
  3. Manage infection prevention and control activities
  4. Provide consultation on infection risk assessment, prevention, and control strategies
  5. Monitor the cleaning of the glucometers
• Read 24 hour report daily – use this info as a double check for infection control issues.
• Rounds on each floor to check boards for infections.
• Review all charts of residents with infections.
• Assure the wet task are filled for the nursing carts for daily cleaning twice a week – may delegate.
• Monitor and coordinate the nightshift cleaning schedule for infection control measures.
• Review lab reports daily and put on isolation when needed.
• Order labs for residents who need to come off of isolation.
• Obtain the vaccination records of new admissions and completes the armbands for communication to the hospital
• Map all infections monthly for trends and patterns.
• Distribute new updates on flu activity, TB changes, etc… to physicians, CRNP, and fellow associates as needed.
• Within 72 hours of a new admission, check to assure all vaccines has been given.  If vaccines have not been given, schedule vaccines.
• When an outbreak occurs, line listing to be completed daily, along with notification to health department, etc…
• Complete yearly flu vaccine administration with assistance from licensed staff.  QA will be aware of all of the consents, allergies, and potential complications during this process.
• Files and analyzes 11/7 responsibility, emergency cart ,cleaning schedules, glucometer checks, alarm checks, and lift battery checks and requires action plan as needed.
• Other duties as assigned.
• Other duties as assigned by Nursing Administration or Administrator.

Required Skills/Abilities:

• Excellent verbal and written communication skills.
• Excellent interpersonal skills
• Excellent organizational skills and attention to detail.
• Excellent time management skills with a proven ability to meet deadlines.
• Strong analytical and problem-solving skills.
• Strong supervisory and leadership skills.
• Ability to prioritize tasks and to delegate them when appropriate.
• Ability to function well in a high-paced and at times stressful environment.
• Ability to be flexible and adaptable
• Proficient with Microsoft Office Suite or related software.
• Access and Maintain a Level 1 to Level 3 SAMS identity verification
• Completion of CDC Infection Prevention training for Long Term Care

Education and Experience:

High school diploma or equivalent.

At least two years related experience required.

Current Nursing license (LPN or RN).

Certificate of Infection Prevention from CDC for Long Term Care

Physical Requirements:

1. moving throughout the organization
2. lifting up to 50 pounds
3. sitting for long periods of time

This job description is includes other duties as assigned and is subject to change as business needs evolve.