1.       Facilitate quality services through adherence to agency and AFC standards. Adhere to the Adult Protective Services and Disabled Persons Protection Commission’s Mandated Reporter Guidelines.

2.       Complete & sign the designed screening tool as required under 130 CMR 408.416 (C) for Mass Health Payment.

3.       Complete the MDS-HC or CDS and other nursing assessments and coordinate all applicable clinical assessments.

4.       Develop and review on an ongoing basis each member’s AFC plan of care. 

5.       Select, train, evaluate and supervise AFC caregivers in conjunction with the Care Manager.

6.       Responsible for reviewing the physician summary.

7.       Monitor the health status of all members to ensure that all needed AFC is properly delivered.

8.       Report changes in the health status of any member to the member’s physician.

9.       Periodic review AFC caregiver logs.

10.   Conduct on-site home visits with each member at the qualified setting as required by regulation;

11.   Complete nursing progress note corresponding with each on-site visit or encounter, or more often as the member’s condition warrants.

12.   Submit a semiannual health-status report to the member’s primary care physician.

13.   Plan for and implement discharges from the AFC program.

14.   Conduct an orientation for each AFC caregiver before the AFC caregiver begins personal care.

15.   Provide ongoing training to AFC caregivers on health and aging and ensure other required trainings are met.

16.   Adhere to agency/personnel and AFC policies and follow emergency and on call procedures.

17.   Participate in conferences, workshops and related trainings to stay abreast of developments in the field.

18.   Represent MCS as needed within the community & with other agencies / organizations with similar objectives.

19.   Practice HIPPA Privacy Rules and the agency’s health information policies and procedures.