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ESSENTIAL CORE FUNCTIONS
Responsibilities
Knowledge
Skill
A Guide for the Consultant Pharmacist, Director of Nursing,
Medical Director, and Nursing Home Administrator
in
Long Term Care Organizations
As put forth by the Long Term Care Professional Leadership Council consisting of:
The American College of Health Care Administrators
The American Medical Directors Association
The American Society of Consultant Pharmacists
and
The National Association of Directors of Nursing Administration
______________________________________________________________________________
The Guide must be read in conjunction with all State and Federal statute and regulations governing
licensed nursing homes and the employer’s policies and position descriptions. The Guide is not intended
to replace or modify any of these State and Federal statutes, regulations or employer policies. In the event
of ambiguity or inconsistency, rules and regulations must take precedence.
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Long Term Care Professional Leadership Council
Charter
The Long Term Care Professional Leadership Council consists of the leaders of the major professional
leadership associations* of long-term care: ACHCA, AMDA, ASCP, and NADONA.
This Council was formed to foster collaboration in defining and addressing issues related to standards for
quality care in long-term care facilities, including:
• Advancing consistent standards, positions, and recommendations pertaining to long-term care
• Promoting evidence-based approaches to common problems and risks of long-term care patients
and residents
• Coordinating and creating cross-disciplinary educational programs
• Improving coordination among key professional disciplines and reducing fragmented and
incompatible initiatives and approaches
• Clarifying accountability for the standard of care as established by law and regulation
• Promoting more effective root cause analysis of commonly identified issues that affect long-term
care performance and practice
• Promoting more effective approaches to improving long-term care
• Offering a united voice on matters that address and advance the quality of services and care for
residents of long-term care facilities
* Those associations representing professional disciplines with administrative accountability for the
quality of care and service provided in the Skilled Nursing Facility as per the requirements in 42 CFR
Part 483, Subpart B.
The Long Term Care Professional Leadership Council believes the essential core functions of each
professional discipline that are contained within this core document are applicable to every long-term care
facility. The Council recognizes and endorses the Maryland Long Term Care Coalition’s description of
Essential Core Functions as described in their Guide for the Charge Nurse, Director of Nursing, Nursing
Home Administrator, Medical Director, and Attending Physician in Comprehensive /Extended Care
Facilities. The core functions advanced in this Guide, are presented here. For more information, please
contact:
American College of Health Care Administrators (ACHCA)
Contact: Marianna Kern Grachek, President & CEO
Phone: 703-739-7900
American Medical Directors Association (AMDA)
Contact: Lorraine Tarnove, Executive Director
Phone: 410-740-9743
American Society of Consultant Pharmacists (ASCP)
Contact: John Feather, Executive Director and CEO
Phone: 703-739-1300
National Association Directors of Nursing Administration/Long Term Care (NADONA)
Contact: Sherrie Dornberger, RN, President
Phone: 513-791-3679
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INTRODUCTION
This document represents an adaptation of the Maryland Long Term Care Coalition which was a
group of professionals who represented an interest and expertise in caring for residents and patients in a
long term care (LTC) facility. This group was formed in an effort to identify essential core functions for:
the licensed nurse in charge of a unit, the Director of Nursing, the Nursing Home Administrator, the
Medical Director, and the Attending Physician. These essential core functions are derived from the
overall roles and responsibilities of contemporary long-term care facilities and the respective standards of
practice for each of these disciplines.
The Long Term Care Professional Leadership Council acknowledges that the routine, essential core
responsibilities and accountability of key personnel were not clearly and concisely identified, nor were
these functions consistently understood by the public at large, regulatory entities or the long-term care
industry. A result of their efforts was the development of documents that described the essential core
functions of each of the key professional roles which have the greatest impact on the LTC resident. The
rationale for the development of these documents included but was not limited to:
1. The identified essential core functions for each position are portable, i.e. skills can be
transported from one facility to another
2. The essential core functions address the minimal expectations for resident safety. Resident care
can be improved; e.g., better resident assessment provides for more thorough, complete communications
with the physician, which can decrease inappropriate resident transfers to acute care hospitals and provide
cost savings.
3. By identifying the essential core functions, ambiguity is minimized, day-to-day expectations of
personnel functioning are established, and accountability and outcome measurements for each position
can be formulated.
4. By identifying essential core functions, an educational plan for assisting professional staff in
acquiring or improving these essential skills can be developed; i.e. not every professional possesses all
essential core skills the first day in the position. The education plan can be developed through in-house
support systems and partnership with a variety of sources. For example:
a) In-house support systems may include both formal and informal options such as
inservice programs, competency testing, mentoring, precepting and informal discussion
groups.
b) Community colleges and universities can develop and offer short-term focused
educational programs; e.g., a six-hour class on analyzing resident population to determine
skill mix.
c) Professional membership associations such as ACHCA, AMDA, NADONA and
ASCP and the LTC trade organizations, such as AHCA and AAHSA can support
leadership development for these key positions; e.g., how to retain control as a NHA and
assign selected financial responsibility to the DON.
d) Professional membership associations can provide short term focused educational
offerings to improve their memberships’ knowledge and skills; e.g., an abbreviated
nursing assessment to use when making shift change rounds.
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Essential Job Functions
Nursing Home Administrator
Any individual who is working as the Nursing Home Administrator in a Skilled Nursing Facility
(SNF) licensed by the state or certified as a Medicare/Medicaid provider should have the
following job skills and perform the following functions. The identification of these jobs
functions/skills is based on the assumptions that:
1. The patient/resident population is frail, complex in nature and experiences many illnesses and
dysfunctions.
2. It is imperative to identify the essential mix of administrative/management skills, knowledge of
fiscal management, ethical principles and decision making skills, and the knowledge of local,
state, federal and other regulatory requirements that the Nursing Home Administrator must
possess or develop in order to lead, administer and manage a long-term care facility.
FRAMEWORK
The framework for the essential core functions are contained in the facility’s job
description/position description for the Nursing Home Administrator. The five principles that
form the organizing framework for the essential core functions include the following:
1. Knowledge and expertise in management of the frail geriatric and other long-term care
patient/resident;
2. Experience and skill in:
a) Leadership and mentoring;
b) Development and implementation of a facility management system;
c) Administration, management, supervision and coordination of all departments
to insure appropriate care;
d) Use of computers and other technological resources;
e) Oversight of a facility quality assurance process;
f) Financial management of a health care facility.
3. Knowledge of pertinent local, state, federal and other regulations and ability to
implement and maintain compliance with these regulations governing the facility,
patient/resident care, and reimbursement;
4. Experience in developing professional relationships and representing the facility in
professional and community activities;
5. Participation in educational programs for continued professional development.
I. RESPONSIBILITIES
The Nursing Home Administrator’s role falls under the following domains and associated tasks:*
A. RESIDENT CARE AND QUALITY OF LIFE
• Ensure that nursing services are planned, implemented, and evaluated to maximize resident
quality of life and quality of care.
• Ensure that social service programs are planned, implemented, and evaluated to meet resident
psychological and social needs and preferences to maximize resident quality of life and quality of
care.
• Ensure that the food service program is planned, implemented, and evaluated to meet the
nutritional needs of residents to maximize resident quality of life and quality of care.
• Ensure that medical services are planned, implemented, and evaluated to meet resident medical
care needs and preferences to maximize resident quality of life and quality of care.
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• Ensure that therapeutic recreation/activity programs are planned, implemented, and evaluated to
meet the needs, and interests of residents to maximize resident quality of life and quality of care.
• Ensure that a health information management program for resident care is planned, implemented,
and evaluated to meet documentation requirements.
• Ensure that a pharmaceutical program is planned, implemented, and evaluated to support medical
care for residents to maximize resident quality of life and quality of care.
• Ensure that a rehabilitation program is planned, implemented, and evaluated to maximize
residents’ optimal level of functioning.
• Identify, monitor, and ensure that quality indicators and quality assurance programs are utilized to
maximize effectiveness in resident care and services.
• Ensure the integration of Resident Rights with all aspects of resident care.
• Ensure development, implementation, and review of resident care policies and procedures.
• Ensure that the facility complies with applicable federal, state, and local standards and
regulations.
B. HUMAN RESOURCES
• Facilitate the process of communication between management and staff (for example, coaching,
counseling).
• Develop, implement, and monitor recruitment, development, evaluation, and retention programs
to provide quality resident care and services (for example recognition programs, job satisfaction
surveys).
• Ensure that human resources programs are planned, implemented, and evaluated to meet resident
and staff cultural diversity needs.
• Develop, implement, and monitor compensation and benefit program for staff.
• Ensure that human resource management policies and programs are planned, implemented, and
evaluated in compliance with governmental entities, laws, and regulations (for example, job
descriptions, education programs, union relations).
• Ensure the development and implementation of employee health and safety programs to provide a
safe work place environment (for example, risk management, OSHA, wellness programs).
C. FINANCE
• Develop and manage annual operating and capital budgets to effectively utilize fiscal resources.
• Develop and implement financial policies, procedures, and systems to monitor financial
performance (for example, accounts payable/ receivable, resident trust).
• Ensure adequate revenue (for example, new sources/services, fund raising, borrowing sources).
• Negotiate, interpret, and implement financial aspects of contractual agreements (for example,
organized labor, managed care, vendor, and consultative services).
• Manage financial audit and reporting systems (for example, corporate compliance, charitability,
information systems).
• Ensure protection of facility assets (for example, insurance coverage, and risk management).
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• Ensure training and education of staff regarding financial management.
D. PHYSICAL ENVIRONMENT AND ATMOSPHERE
• Ensure that a system for maintaining and improving buildings, grounds, and equipment is
planned, implemented, and evaluated.
• Ensure that the facility provides a clean, attractive, and home-like environment for residents,
staff, and visitors.
• Ensure the planning, implementation, and evaluation of an environmental safety program that will
maintain the health, welfare, and safety of residents, staff, and visitors.
• Ensure the planning, implementation, and evaluation of an emergency program that protects the
safety and welfare of residents, visitors, staff, and property.
• Identify, monitor, and ensure that quality assurance programs are utilized to maximize
effectiveness in environmental services.
• Ensure the integration of resident rights with all aspects of the facility environment.
• Ensure development, implementation, and review of environmental policies and procedures.
• Ensure that facility complies with applicable federal, state, and local standards and regulations
(for example, ADA, OSHA, CMS, Life Safety Code).
• Ensure a comprehensive preventative maintenance program is developed and implemented.
E. LEADERSHIP AND MANAGEMENT
• Ensure that policies and procedures are developed, implemented, monitored, and evaluated in
order to maintain compliance with directives of governing entities.
• Ensure that policies and procedures are developed, implemented, monitored, and evaluated in
order to maintain compliance with federal, state, and local rules and regulations.
• Observe, monitor, and evaluate outcomes of all of the facility’s programs, policies, and
procedures, to ensure effectiveness, and to fulfill administrative responsibility (for example, facility
license) and professional responsibility (for example, personal NHA license).
• Promote residents and families/responsible parties’ satisfaction with quality of care and quality of
life.
• Ensure administrative oversight of the survey process.
• Conduct administrative review of survey outcomes to develop appropriate response (for example,
no response, preparation of plan of correction, preparation of documentation for Informal Dispute
Resolution [IDR]).
• Educate staff/residents/families/responsible parties and other key groups in regards to
interpretation of and compliance with regulatory requirements.
• Educate nursing home board and/or governing entity regarding their roles and responsibilities,
and monitor their actions to ensure adherence to by-laws and regulations.
• Identify areas of potential legal liability, and develop and implement an administrative
intervention or risk management program to minimize or eliminate exposure.
• Develop or influence a strategic planning process to ensure viability of facility.
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• Participate in professional development activities.
• Develop leadership skills of management team and key staff.
• Ensure that information management systems are in place to support facility operations.
• Ensure that resources (for example, supplies, medical equipment, technology, trained staff) are in
place to provide resident care and to promote quality of life.
• Develop and implement a comprehensive marketing and consumer education program.
• Develop and implement a media relations program including proactive (for example, promoting
positive images about the facility and/or industry) and reactive programs (for example, situation-
specific responses to adverse incidents).
• Plan, implement, and provide integration between the facility and other community resources (for
example, educational institutions, hospitals, vendors).
• Monitor the political climate and formulate action to affect the political process.
II. KNOWLEDGE AND SKILLS
A. RESIDENT CARE AND QUALITY OF LIFE
Knowledge of:
• Federal, state and local standards and regulation
• Aging process (psychological)
• Aging process (physiological)
• Definition, concept, and basic principles of nursing
• Basic principles of restorative nursing
• Basic principles of rehabilitation
• Basic principles of infection control
• Basic principles and regulations for handling administration, labeling, record keeping, and destruction
of drugs and biologics
• Resident care needs
• Resident Assessment Instrument (RAI) and interdisciplinary care plan requirements and process
• Admission, transfer, and discharge requirements/regulations
• Techniques of auditing resident care and service outcomes
• Roles of resident care staff and consultants
• Physiological, social, emotional, psychological, spiritual, financial, and legal service needs of
residents and their families
• Communication techniques
• Dynamics of interpersonal relationships
• Available resources (for example, community, social, financial)
• Grieving process
• Death and dying
• Group dynamics
• Resident rights
• Advanced directives
• Basic nutritional requirements
• Basic principles of food storage, handling, preparation, and presentation
• Resident dining experience
• Meal frequency
• Therapeutic or specialized diets
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• Principles of dietary sanitation
• Food service delivery
• Nutritional supplements
• Basic medical terminology
• Provision of basic specialty medical services (for example, optometry, podiatry, dental, psychiatry,
psychology)
• Role of physician services
• Role of medical director
• Frequency of physician visits
• Provision of emergency medical services
• Physician/resident relationship(s)
• Quality assurance processes as it relates to resident care and services
• Basic therapeutic recreation/activity needs of residents
• Clinical medical record content and format
• Federal documentation requirements
• Chemical and physical restraints
• Confidentiality and safeguarding clinical record information
• Centers for Medicare and Medicaid Services (CMS) quality indicators
Skill in:
• Recognizing whether or not resident needs are met.
• Utilizing basic counseling methods and crisis intervention techniques
• Relationship building
• Analyzing and interpreting customer satisfaction data
• Interpreting Centers for Medicare and Medicaid (CMS) quality indicators
• Analyzing and interpreting effectiveness of quality assurance data related to resident care and service
outcomes.
• Interpersonal communication (for example, individuals from diverse backgrounds, cognitively
impaired residents)
B. HUMAN RESOURCES
Knowledge of:
• Methods of communication
• Communication technology (for example, e-mail, voice mail, computer software)
• Criminal background checks/nursing assistant registry
• Employee interview procedures
• Facility staffing needs and requirements
• Staff position qualifications
• Staff licensure requirements
• Staff education/in-service requirements
• Confidentiality requirements
• Recruitment and retention methods
• Employment history and verification methods
• Drug-free workplace programs
• Staff development requirements, resources, and models
• Staff corrective action methods
• Staff recognition and appreciation techniques
• Employee evaluation process
• Staff scheduling techniques
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• Federal, state, and local labor and civil rights laws
• Federal and state rules and regulations (for example, Family Medical Leave Act, Occupational Health
and Safety Act, Americans with Disabilities Act, Equal Employment Opportunity Commission)
• Safety programs and requirements
• Worker’s compensation rules and procedures
• Injury-prevention and return-to-work program
• Ethical behavior of staff
Skill in:
• Written and oral communication
• Coaching, counseling, and teaching
• Facilitating group meetings (for example, departmental staff meetings)
• Negotiating
• Interviewing (for example, pre-employment, investigations, exit)
• Analyzing and interpreting employee performance
• Team-building
• Motivating employees
• Analyzing and interpreting human resource programs
C. FINANCE
Knowledge of:
• Budgeting methods and financial planning
• Accounting methods (for example, Generally Accepted Accounting Practices, cash and accrual) and
regulatory requirements
• Financial statements
• Reimbursement sources and methods (for example, Medicare, Medicaid, managed care)
• Federal, state, and local regulations affecting nursing home reimbursement
• Potential revenue sources
• Internal controls (for example, purchasing, inventory, accounting, departmental)
• Payroll procedures and documentation
• Accounts receivable, collection, and billing procedures
• Accounts payable procedures
• Risk management
• Eligibility and coverage requirements from third party payors
Skill in:
• Analyzing and interpreting budgets and financial statements
• Interpreting financial regulations as they apply to reimbursement
• Managing cash flow
• Analyzing and identify trends in financial performance of facility
D. PHYSICAL ENVIRONMENT AND ATMOSPHERE
Knowledge of:
• Preventative maintenance systems
• Equipment needs and management
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• Local, state, and federal codes, rules and regulations for buildings, grounds, equipment and
maintenance including ADA, OSHA, Life Safety Codes, and NFPA
• Roles of environmental staff (such as housekeeping, maintenance, laundry)
• Waste management, including infectious waste
• Basic housekeeping concepts and procedures
• Basic sanitation concepts and procedures
• Basic infection control concepts and procedures
• Pest control
• Basic concepts regarding personal protective equipment (PPE)
• Potential hazards (for example, biohazards, blood-borne pathogens, hazardous materials)
• Security measures
• Elements of fire and disaster programs
• Community emergency resources
• In-house emergency equipment
• Evacuation resources and requirements
• Emergency procedures (for example, elopements, personal injuries)
• Quality assurance as it relates to environmental services
Skill in:
• Analyzing physical plant needs
• Recognizing environmental impact on residents
• Analyzing and interpreting effectiveness of quality assurance data related to environmental service
and safety outcomes
• Interpreting and applying safety codes
• Interpreting and implementing life safety codes
• Crisis management
• Interpersonal communication
E. LEADERSHIP AND MANAGEMENT
Knowledge of:
• Federal, state and local laws, regulations, agencies and programs such as Medicare, Medicaid,
Occupational Safety and Heath Administration (OSHA), Americans with Disabilities Act (ADA),
Fair Labor Standards Act (FLSA), Equal Employment Opportunity Commission (EEOC), Safe
Medical Devices Act (SMDA)
• Corporate compliance
• Potential legal liability of the facility
• Potential legal and criminal liability of administrator
• Codes of ethics of professional associations and standards of practice of state boards
• Quality improvement models (for example, continuous quality improvement (CQI), quality assurance
(QA), total quality management (TQM), performance improvement (PI))
• Facility licensing requirements
• Certification survey tasks
• Quality indicators reports and on-line survey certification reports (OSCAR)
• Survey process including scope and severity grid as well as remedies and acceptable plan of
correction
• Management information systems
• Technology to support facility operations (for example, medical, security, environmental, work-place
safety)
• The role of each component of long-term care in the healthcare continuum
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• Functions of all departments and services provided
• Management principles and philosophies
• Methods for assessing and monitoring resident and responsible parties’ satisfaction with quality of
care and quality of life
• Techniques of conflict resolution
• Grievance procedures for residents and families/responsible parties
• Resident rights
• The role of the resident ombudsman
• Oral and written communications techniques
• Risk management principles
• Public relations and marketing techniques
Skill in:
• Interpreting rules and regulations, and policies and procedures
• Managing the change process
• Analyzing facility compliance
• Identifying relevant information
• Prioritizing alternative solutions
• Using basic counseling methods
• Negotiating techniques
• Problem solving
• Time management
• Conflict resolution and mediation
• Oral and written communications skills
• Cultivating effective relationships
• Managing organizational behavior
* Reprinted with permission of the NAB: Job Analysis of Nursing Home Administrators; © 2002,
National Association of Boards of Examiners of Long Term Care Administrators. 1444 I Street, NW,
#700 Washington DC, 20005-2210. All rights reserved. No part of this document may be reproduced in
any form without the written permission of the NAB.
III ACHCA CODE OF ETHICS (adopted by NAB 2006)
PREAMBLE: The preservation of the highest standards of integrity and ethical principals is vital to the
successful discharge of the professional responsibilities of all long-term health care administrators. This
Code of Ethics has been promulgated by the American College of Health Care Administrators (ACHCA)
in an effort to stress the fundamental rules considered essential to this basic purpose. It shall be the
obligation of members to seek to avoid not only conduct specifically proscribed by the code, but also
conduct that is inconsistent with its spirit and purpose. Failure to specify any particular responsibility or
practice in this Code of Ethics should not be construed as denial of the existence of other responsibilities
or practices. Recognizing that the ultimate responsibility for applying standards and ethics falls upon the
individual, the ACHCA establishes the following Code of Ethics to make clear its expectation of the
membership.
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EXPECTATION I
Individuals shall hold paramount the welfare of persons for whom care is provided.
PRESCRIPTIONS: The Health Care Administrator shall:
• Strive to provide to all those entrusted to his or her care the highest quality of appropriate services
possible in light of resources or other constraints.
• Operate the facility consistent with laws, regulations, and standards of practice recognized in the field
of health care administration.
• Consistent with law and professional standards, protect the confidentiality of information regarding
individual recipients of care.
• Perform administrative duties with the personal integrity that will earn the confidence, trust, and
respect of the general public.
• Take appropriate steps to avoid discrimination on basis of race, color, sex, religion, age, national
origin, handicap, marital status, ancestry, or any other factor that is illegally discriminatory or not related to
bona fide requirements of quality care.
PROSCRIPTION: The Health Care Administrator shall not:
• Disclose professional or personal information regarding recipients of service to unauthorized
personnel unless required by law or to protect the public welfare.
EXPECTATION II
Individuals shall maintain high standards of professional competence.
PRESCRIPTIONS: The Health Care Administrator shall:
• Possess and maintain the competencies necessary to effectively perform his or her responsibilities.
• Practice administration in accordance with capabilities and proficiencies and, when appropriate, seek
counsel from qualified others.
• Actively strive to enhance knowledge of and expertise in long-term care administration through
continuing education and professional development.
PROSCRIPTIONS: The Health Care Administrator shall not:
• Misrepresent qualifications, education, experience, or affiliations.
• Provide services other than those for which he or she is prepared and qualified to perform.
EXPECTATION III
Individuals shall strive, in all matters relating to their professional functions, to maintain a professional
posture that places paramount the interests of the facility and its residents.
PRESCRIPTIONS: The Health Care Administrator shall:
• Avoid partisanship and provide a forum for the fair resolution of any disputes which may arise in
service delivery or facility management.
• Disclose to the governing body or other authority as may be appropriate, any actual or potential
circumstance concerning him or her that might reasonably be thought to create a conflict of interest or have
a substantial adverse impact on the facility or its residents.
PROSCRIPTION: The Health Care Administrator shall not:
• Participate in activities that reasonably may be thought to create a conflict of interest or have the
potential to have a substantial adverse impact on the facility or its residents.
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EXPECTATION IV
Individuals shall honor their responsibilities to the public, their profession, and their relationships with
colleagues and members of related professions.
PRESCRIPTIONS: The Health Care Administrator shall:
• Foster increased knowledge within the profession of health care administration and support research
efforts toward this end.
• Participate with others in the community to plan for and provide a full range of health care services.
• Share areas of expertise with colleagues, students, and the general public to increase awareness and
promote understanding of health care in general and the profession in particular.
• Inform the ACHCA Standards and Ethics Committee of actual or potential violations of this Code of
Ethics, and fully cooperate with ACHCA’s sanctioned inquiries into matters of professional conduct related
to this Code of Ethics.
PROSCRIPTION: The Health Care Administrator shall not:
• Defend, support, or ignore unethical conduct perpetrated by colleagues, peers or students.
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Essential Job Functions
Director of Nursing
Any registered nurse who is working as the Director of Nursing of a Skilled Nursing Facility (SNF)
licensed by the state and/or certified to be a Medicare/Medicaid provider should have the following job
skills and perform the following functions. The identification of these job functions/skills is based on the
assumptions that:
1) the patient/resident population is frail, complex in nature and experiences many
illnesses and dysfunctions.
2) it is imperative to identify the essential mix of nursing clinical skills; management and
leadership skills; and knowledge of fiscal management, ethical principles, state and
federal regulatory requirements and standards of professional nursing practice that the
Director of Nursing must possess in order to develop and implement a system of nursing
care that meets the needs of the facility’s patient/resident population.
FRAMEWORK
The framework for the essential core functions is contained in the facility’s job description /
position description for the Director of Nursing. The five principles that form the organizing framework
for the essential core job functions include:
1. Knowledge and expertise in nursing management of the geriatric and other long-term care
patient/resident.
2. Experience and skill in:
a. leadership and mentoring;
b. development and implementation of a system of nursing that includes the ability to
analyze and identify personnel resource needs and skills;
c. administrative management and supervision of licensed and unlicensed personnel in
the delivery of nursing care; and the identification and proper utilization of the skill mix
of nursing personnel;
d. coordination of nursing services with all other departments to ensure appropriate care;
e. knowledge in basic computer skills and other technological resources;
f. ability to develop and implement an ongoing quality assurance process.
3. Knowledge of state and federal regulations and ability to implement and maintain compliance
with these regulations governing the facility, resident care, and reimbursement;
4. Development of professional relationships and representation of the facility and nursing service
in professional and community activities;
5. Expansion of knowledge base and improvement of nursing skills by continued professional
development, including attendance at educational programs, etc.
I. RESPONSIBILITIES
The Director of Nursing has functions and tasks associated with his or her role. These functions
and tasks include:
A. Responsible to the owner/governing body/licensed administrator for:
1) the overall coordination and execution of nursing services and
2) monitoring and evaluating the outcomes of nursing care.
B. Providing nursing oversight. The Director of Nursing should:
1. oversee all staff who provide nursing care to the facility’s residents / patients;
2. ensure that there is a procedure to collect and review nursing staff=s licensure /
certification / credentials;
3. establish rules governing the conduct of nursing staff; and,
4. ensure that all nursing staff are held accountable for the care they deliver to residents /
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patients in the nursing facility.
C. Defining the scope of nursing services. The Director of Nursing should develop written
policies and procedures which are approved by the owner / governing body / licensed
administrator, related to the scope of nursing services and nursing care that should be provided to
a facility’s residents / patients, upon and after admission.
D. Ensuring nursing accountability. The Director of Nursing should implement and enforce
policies and procedures that cover essential nursing responsibilities to the residents / patients and
the facility including:
1. accepting responsibility for the care of residents / patients;
2. supporting resident / patient discharges and transfers; and
3. providing adequate ongoing nursing coverage;
4. providing appropriate, timely and pertinent documentation.
E. Care quality assessment and improvement. The Director of Nursing should participate actively
in the facility’s quality improvement process. Such participation should include:
1. regular attendance at, and reporting to, the facility’s quality improvement committee
meetings; and
2. routine participation in ongoing facility efforts to improve the overall quality of the
nursing care, including facility efforts to evaluate and address the causes of various care-
related problems and deficiencies.
F. Clinical. The Director of Nursing ensures that nursing practice in the facility reflects the
following nursing skills:
1. skill in resident assessment, critical thinking and nursing interventions;
2. oversight of the interdisciplinary care planning process to include initial planning (on
admission to the unit); interim planning (to include clinical status changes); and the
required Resident Assessment Instrument (RAI);
3. evaluation of whether the nursing care facility can meet each resident / patient’s needs,
which includes the potential new admission to the facility, a current resident of the
facility, or the transfer of a resident from the facility.
G. Administration. The Director of Nursing should:
1. Develop and implement an organized nursing system for the delivery of care and
services which may include but is not limited to:
a. coordination of nursing services with other services and departments; i.e.
pharmacy, dietary, housekeeping, laundry, activities, social services, accounting,
maintenance, medical records, medical services, etc;
b. work with other management personnel to facilitate delivery of nursing
services and other services.
2. Utilize the expertise of other departments and services to address nursing issues in
facilitating delivery of resident services;
3. Develop the nursing budget for the nursing department to include but not limited to:
a. Hours of care per day per patient;
b. Staffing mix to deliver hours of care;
c. Necessary supplies and technological resources.
4. Direct nursing preparation for review and response to federal, state and local surveys
and inspections.
H. Management and Nursing Oversight: The Director of Nursing should:
1. ensure that nursing practice complies with regulatory and legislative requirements;
2. help develop and implement immunization programs for patients and staff;
3. conduct clinical rounds on all nursing units;
4. promote, establish, and maintain customer relationships with residents, families, staff,
community and other professionals;
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5. identify and access available resources to develop and implement an ongoing
educational plan appropriate for each level of nursing staff;
6. develop and implement policies, procedures and programs regarding communicable
diseases, infection control and isolation procedures;
7. develop and implement policies and procedures for pain assessment and management;
8. develop and implement policies, procedures and programs regarding abuse, neglect
and violence prevention, in collaboration with the Nursing Home Administrator.
II. KNOWLEDGE AND SKILLS
The Director of Nursing has knowledge and skills related to the following:
1. basic nursing practice and principles;
2. basic medical and geriatric principles and concepts;
3. basic administrative principles and practices.
4. regulatory, social, political and economic issues that relate to provision of nursing
services in the long-term care setting;
A. Long-Term Care Setting
1. The environment of long-term care, the continuum of care, and the place of long-term
care in that continuum;
2. The goals of long-term care;
3. Resident rights, and the nursing role in helping protect and enhance those rights;
4. Principles and processes related to ethical issues in the chronically and acutely ill;
5. Strategies to improve the processes and outcomes of managing various levels of
illnesses in the nursing facility population, including chronic conditions, emergencies,
condition changes and terminal events;
6. Nursing’s role in the interdisciplinary approach to long-term care;
7. Reimbursement issues and strategies for long-term care facilities.
B. Institutionalized Individuals
1. Issues, principles and processes related to institutional life and family involvement in
long-term care, and nursing responsibilities in helping optimize that participation;
2. Basic principles of, and requirements for, documentation and medical record
management.
C. Communication
1. Skill at interviewing and extracting clinical information from other care providers;
2. Skill at integrating and assimilating clinical information gained from other care
providers;
3. Skill at making nursing decisions regarding nursing care needs of the resident(s) /
patient(s);
4. Skill at organizing and presenting information systematically;
5. Skills in effective listening and critical observations and utilizing the information
gained for effective problem solving.
D. Leadership/Management
1. Possesses interpersonal, verbal and written communication skills;
2. Demonstrates leadership skills in principles of team building, motivating others,
conflict management/resolution and negotiation;
3. Facilitates and teaches staff how to identify and solve problems;
4. Exhibits time management, prioritizing and critical thinking skills;
5. Analyzes and solves problems utilizing appropriate decision-making models for
problem solving;
6. Delegates nursing, administrative, and human resource management functions.
7. Leads by example by providing professional support for staff and by assisting staff
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with direct and indirect patient/resident care through prioritizing patient/resident needs,
human resources and nursing administration goals.
E. Finances
1. Knowledge of principles and processes of financial management, reimbursement,
budgeting and information systems;
2. Knowledge of current health care climate and implications for reimbursement and
expenditures;
3. Knowledge of system and processes for monitoring the nursing department’s financial
status;
4. Knowledge and principles of accurately reporting clinical and financial information as
it relates to third party fraud and/or patient abuse.
III. CODE OF CONDUCT
The Code of Conduct requires the Director of Nursing to have knowledge of and demonstrate
core competencies in ethical conduct. These actions would include but are not limited to:
1. Investigating, documenting and reporting per facility and procedure, any observed or suspected
substance abuse among patient/resident, families, significant others, coworkers, or employer.
2. Investigating, documenting, and reporting, according to facility protocol, any suspected or
observed violation of resident rights.
3. Investigating, documenting and reporting, per facility policy and procedure, any suspected or
observed abuse or neglect of patients, families, significant others, visitors, coworkers or
employer.
4. Investigating, documenting and reporting, per facility policy and procedure, suspected or
observed fraudulent documentation by coworkers or employee.
5. Acknowledging multi-cultural differences among patient/resident, family members/ significant
others, members of the health care team, and the employer.
6. Refraining from taking advantage of professional relationships for personal gain, i.e. vendors,
co-workers, patient/resident or family/significant others.
7. Utilizing basic communication skills to resolve conflict by:
a. utilizing appropriate verbal language and non-verbal behavior to clarify and resolve
disagreements;
b. seeking clarification from the administrator and/other colleagues as appropriate for
areas of dispute or concern.
8. Investigating, documenting and reporting, per facility policy and procedure, incidents of
violence in the workplace to include patient/resident and family/significant other, coworker and
other members of the health care team;
9. Creating a system that:
a. assures that patient/resident and family/significant others receive pertinent and accurate
information about the patient/resident’s current status consistent with the wishes of the
patient/resident, and if applicable, the patient/resident’s legal representative;
b. maintains confidentiality of patient/resident information;
c. restricts discussion of work related issues to appropriate times and places.
10. Demonstrates courteous behavior to patient/resident, family/significant other, coworkers,
other members of the health care team, and the employer.
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Essential Job Functions
Medical Director
Any Medical Director who has oversight responsibility for the patients/residents in a Skilled Nursing
Facility (SNF) licensed by the state or certified as a Medicare/Medicaid provider should have the
following job skills and perform the following functions. The identification of these
functions/skills is based on the assumptions that:
1. The patient/resident population is frail, complex in nature and experiences many illnesses and
dysfunctions.
2. It is imperative to identify the essential mix of: management skills; knowledge of fiscal
implications of clinical decisions, ethical principles, and decision making skills; and the
knowledge of State and Federal regulatory requirements.
FRAMEWORK
The framework for the core functions is contained in the facility’s job description/ position
description for the Medical Director. The four principal roles and responsibilities of the Medical Director
that form the organizing framework for the core job functions include the following:
1. Planning: establishing goals and objectives; selecting desirable programs and services.
2. Organizing: developing a medical staff structure; developing programs and services.
3. Leading: ensuring an effective approach to care; promoting practice consistent with geriatric
and medical principles.
4. Managing: holding individuals accountable; analyzing and solving problems; providing
feedback to improve individual performance.
I. RESPONSIBILITIES
The Medical Director has functions and tasks associated with his or her roles.
A. The Medical Director is responsible to the owner/governing body/licensed administrator for:
1. the overall coordination, execution, and monitoring of physician services and
2. monitoring and evaluating the outcomes of the health care, including clinical and
physician services, provided to the facility’s patients/residents.
B. The Medical Director provides Practitioner oversight by:
1. overseeing all physicians and other licensed health care practitioners who provide
health care to the facility’s patients/residents;
2. ensuring that there is a procedure to collect and review practitioners’ credentials;
3. establishing rules governing the conduct of physicians and other licensed health care
practitioners admitting patients/residents to the facility; and,
4. ensuring that all licensed health care practitioners are held accountable for the care
they deliver to patients/residents in the nursing facility.
C. The Medical Director defines the scope of medical services by:
1. developing appropriate written policies and procedures, which are approved by the
owner / governing body / licensed administrator.
2. establishing policies and procedures that relate to the scope of physician services and
medical care that are provided to a facility’s residents/patients, upon and after admission.
3. ensuring that policies, procedures, and practice protocols are consistent with care
standards and state and federal regulations relevant to the population served.
D. The Medical Director ensures physician accountability. The Medical Director implements and
enforces policies and procedures that cover essential physician responsibilities to the
patients/residents and the facility, including:
1) accepting responsibility for the care of patients/residents;
2) supporting patient/resident discharges and transfers;
3) making periodic, pertinent patient/resident visits in the facility;
4) providing adequate ongoing medical coverage;
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5) providing appropriate patient/resident care;
6) providing appropriate, timely medical orders;
7) providing appropriate, timely, and pertinent documentation; and
8) any other responsibilities as determined by the facility and the medical director.
E. The Medical Director participates actively in the facility’s quality improvement process. Such
participation includes:
1) regular attendance at, and reporting to, the facility’s quality improvement committee
meetings; and,
2) routine participation in ongoing facility efforts to improve the overall quality of the
clinical care, including facility efforts to evaluate and address the causes of various care-
related problems and deficiencies.
F. The Medical Director helps establish and maintain surveillance of the health status of
employees including:
1) advising on the development and execution of an employee health program, which
should include provisions for determining that employees are free of communicable
diseases according to current accepted standards of practice; and,
2) ensuring that the facility plans and carries out required immunization programs.
G. The Medical Director performs other essential duties related to clinical care and physician
practices including:
1) advising the Administrator and the Director of Nursing on clinical issues, including the
criteria for patients/residents to be admitted, transferred or discharged from the nursing
facility;
2) working with the nursing facility to establish appropriate relationships with area
hospitals and other pertinent institutions;
3) advising and consulting with the nursing facility staff regarding communicable
diseases, infection control and isolation procedures, and serving as a liaison with local
health officials and public health agencies that have policies and programs that may
affect the nursing facility’s care and services to patients/residents;
4) providing temporary physician services as needed to ensure that each patient/resident
has continuous physician coverage;
5) participating, as appropriate, in facility committee projects and meetings concerning
clinical care and quality improvement that require physician input;
6) helping to prepare for, review, and respond to federal, state, and local surveys and
inspections;
7) educating and informing all physicians about their roles, responsibilities, and
applicable rules and regulations; and
8) advising and consulting with the attending physicians and nursing facility staff
regarding the provision of cost-effective care, and financial factors affecting clinical
practices and the provision and quality of care.
II. KNOWLEDGE AND SKILLS
The Medical Director has knowledge and skills related to the following:
1. basic medical and geriatrics principles and practices.
2. social, regulatory, political, and economic factors that relate to patient/resident care services in
the long-term care setting.
A) Long-term care setting
1. infection control principles and practices relative to long-term care facilities;
2. employee health principles and practices relative to long-term care facilities;
3. the environment of long-term care, the continuum of care, and the place of long-term
care in that care continuum;
4. roles and functions of nursing facilities in the care continuum;
5. the goals of chronic and acute care;
20
6. resident rights, and the physician role in helping protect and enhance those rights;
7. important issues, principles, laws, and processes related to managing ethical issues in
chronically and acutely ill individuals.
B. Institutional care
1. issues, principles, and processes related to family involvement in long-term care, and
the physician's role in helping to optimize that participation;
2. how the medical director can influence the quality of long-term care, including the
medical care;
3. principles and tools for improving quality in long-term care settings;
4. how medical directors can help improve long-term care by influencing nursing facility
operations.
C. Facilities and the performance of individual staff and practitioners
1. basic principles of, and requirements for, documentation and medical record
management for long-term care;
2. areas of risk in the nursing facility and in the care of chronically ill institutionalized
elderly, and strategies for identifying, anticipating, and reducing such risks;
3. strategies to improve the processes of managing, and the outcomes of, various levels of
illness in the nursing facility population, including chronic conditions, emergencies,
condition changes, and terminal events;
4. the physician's role in the interdisciplinary approach to long-term care;
5. the management structure and functions of health care organizations;
6. principles, styles, and practices of leadership and management;
7. the medical director's leadership and management functions in long-term care
facilities;
8. appropriate roles, functions, and tasks for various participants in a health care
organization;
9. important elements of a medical director's agreement (contract);
10. how to organize and oversee physicians and other health care practitioners in long-
term care settings;
11. basic reimbursement issues and strategies for long-term care facilities and physicians;
12. the options, roles, functions, and impact of governance of long-term care facilities;
13. strategies for a medical director to communicate to others about important issues and
concerns.
III. CODE OF CONDUCT
The medical director should adhere to the following code of ethical conduct:
1. Keep the well-being of patients/residents as the principal consideration in all activities and interactions.
2. Be alert to, and report, any observed or suspected violation of patient/resident rights consistent with
facility policy and procedure.
3. Be alert to, and report, any suspected or observed abuse or neglect of patient/resident, family/
significant other, visitors, co-workers or employer consistent with facility policy and procedure.
4. Be alert to, and report per facility policy and procedure suspected or observed fraudulent
documentation by co-workers or employer.
5. Acknowledge the multicultural customs and values of patient/resident, family/significant other, other
members of the health care team, and the employer.
6. Refrain from taking advantage of the professional relations for personal gain, i.e. with vendors, co-
workers, patient/resident, and family/significant others.
7. Utilize basic communication skills to resolve conflict by:
a. Utilizing appropriate actions and language to clarify and resolve disagreements with
patient/resident, family/significant other, facility employees and administrative personnel, and
attending physicians.
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b. Seeking clarification regarding areas of dispute or concern from the administrator as
appropriate.
8. Help create a system that:
a. assures that patient/resident’s, family/significant other or legal representatives receive pertinent
and accurate information about the patient/resident’s current status consistent with the wishes of
the patient/resident.
b. Maintains confidentiality of patient/resident information.
9. Demonstrate courteous behavior to patient/resident, family/significant other, co-workers, other
members of the health care team, and the employer.
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Essential Job Functions
Consultant Pharmacist
The Consultant Pharmacist for a nursing facility should have the following job skills and perform the
following functions. The identification of these functions/skills is based on the assumptions that:
1. The patient/resident population is frail, complex in nature and experiences many illnesses and
dysfunctions.
2. It is imperative to identify the essential mix of: management skills; knowledge of geriatric
medication use principles and fiscal implications of clinical decisions; ethical principles; problem
solving and decision making skills; and the knowledge of State and Federal regulatory
requirements that the Consultant Pharmacist must possess in order to develop and implement
facility systems related to medication use and pharmacy services to meet the needs of facility
residents.
FRAMEWORK
The framework for the core functions is contained in the facility’s job description/ position
description for the Consultant Pharmacist. The principles that form the organizing framework for the
Consultant Pharmacist essential core job functions include the following:
1. Knowledge and expertise in drug therapy management of the frail geriatric and other long-term
care patient/resident;
2. Knowledge of pertinent state and federal laws, regulations, and survey guidance pertaining to
medications and pharmacy services related to long-term care facilities and patient/residents;
3. Experience and skill in:
a) institutional drug distribution systems and medication safety
b) communicating and coordinating with the interdisciplinary team
c) quality improvement
d) infection control and immunization programs
e) problem solving
4. Participation in educational programs for continued professional development
I. RESPONSIBILITIES
The Consultant Pharmacist has functions and tasks associated with his or her roles.
A. The Consultant Pharmacist is responsible to the facility administrator to:
1. provide consultation on all aspects of the provision of pharmacy services in the facility
2. coordinate pharmaceutical services if and when multiple pharmaceutical services
providers are utilized (e.g. pharmacy, infusion, prescription drug plans, hospice)
3. review the drug regimen of each resident in the facility at least monthly
4. report any drug regimen irregularities to the attending physician and director of nursing
5. establish a system of records of receipt and disposition of all controlled drugs in
sufficient detail to enable an accurate reconciliation
6. determine that drug records are in order and that an account of all controlled drugs is
maintained and periodically reconciled
B. The Consultant Pharmacist assists the facility in developing and implementing policies and
procedures that address:
1. the provision of routine and emergency medications to its residents in a timely manner
[NOTE: medications means drugs and biologicals]
2. prescribing of medications, and receiving and interpreting prescriber’s orders
3. acquiring, receiving, storing, controlling, reconciling, packaging and labeling of
medications
4. compounding (including sterile products such as intravenous antibiotics) and
dispensing of medications
5. distributing and administering of medications
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6. disposing of all medications and chemicals (e.g. hydrogen peroxide, povidone iodine)
7. accountability of controlled drugs
8. monitoring responses to medications and communication of this information to the
multidisciplinary team
9. prevention, identification and reporting of medication errors and adverse drug
reactions
10. immunization of facility residents and staff
11. other pertinent issues related to pharmacy services and medication use in the facility
C. The Consultant Pharmacist collaborates with the facility Medical Director to:
1. educate attending physicians and direct care staff about risks and benefits of
medication use, proper processes for making decisions about the need for medications,
and how symptoms and condition changes in specific residents may relate to the benefits
and adverse consequences of medications
2. promote a proper care process in the nursing facility because of the importance of
adequately detailed and accurate information in helping correctly identify causes and
symptoms and avoid unnecessary medications
3. reconcile cost and clinical considerations in relation to medication utilization and to
promote a more efficient and clinically conscious approach to documentation required for
drug authorization and exceptions
4. address issues and concerns regarding medication utilization, consultative
recommendations, and physician responses to those recommendations
D. The Consultant Pharmacist participates actively in the facility’s quality improvement process.
Such participation includes:
1) regular attendance at, and reporting to, the facility’s quality improvement committee
meetings;
2) routine participation in ongoing facility efforts to improve the overall quality of
medication use, including facility efforts to identify, report and evaluate medication
errors and adverse drug reactions; and
3) evaluating and reporting on patterns of use of antibiotics and supporting facility
systems to prevent and manage infections, particularly with regard to multidrug-resistant
organisms
4) evaluating and reporting on overall patterns of medication use, including psychotropic
medications, and the potential contribution of medication use to overall facility quality of
care issues, including such areas as falls, urinary incontinence, etc.
E. The Consultant Pharmacist performs other essential duties related to clinical care of residents
including:
1) helping facility staff to prepare for, review, and respond to federal and state surveys
and inspections
2) assisting in development and implementation of protocols for safe and effective use of
medications or therapies with high potential for toxicity or adverse effects (e.g. warfarin)
3) assisting in development and implementation of clinical practice guidelines for facility
residents (e.g. heart failure, pressure sores)
4) assisting in development and implementation of protocols for safe and effective
transitions of care (e.g. between nursing facility and hospital or emergency room),
especially in regard to medication orders
5) participating, as appropriate, in facility committee projects and meetings concerning
clinical care and quality improvement that require pharmacist input
6) regularly monitoring facility compliance with policies, procedures, protocols, and
guidelines relating to medication use in the facility
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II. KNOWLEDGE AND SKILLS
The Consultant Pharmacist has knowledge and skills related to the following:
1. basic medical and geriatric principles and concepts;
2. principles of geriatric medication use;
3. institutional drug distribution systems;
4. social, regulatory, political and economic factors that relate to patient/resident care services in
the long-term care setting.
A) Long-term care setting
1. the environment of long-term care, the continuum of care, and the place of nursing
facilities in that care continuum;
2. the pharmacist’s role in the interdisciplinary approach to long-term care;
3. infection control principles and practices relative to long-term care facilities, including
immunization of residents and staff;
4. the goals of drug therapy;
5. important issues, principles, laws, and processes related to managing clinical and
ethical issues in long-term care residents.
B. Institutionalized individuals
1. issues, principles, and processes related to institutionalized life, including resident
rights and family involvement in long-term care
2. principles and tools for improving quality of care for institutionalized individuals.
C. Communication
1. effective in both verbal and in written communication;
2. skill at organizing and presenting information systematically;
3. skill in effective listening and critical observation and utilizing the information gained
for effective problem solving;
4. knowledge of strategies for a Consultant Pharmacist to communicate effectively to
others about important issues and concerns.
D. Finances
1. knowledge of payment structures for long-term care facilities (e.g. Medicare,
Medicaid)
2. reimbursement issues and strategies related to medications
3. important elements of a Consultant Pharmacist’s agreement (contract);
III. CODE OF CONDUCT
The Consultant Pharmacist should adhere to the following code of ethical conduct:
1. Keep the well-being of patients/residents as the principal consideration in all activities and interactions.
2. Be alert to, and report, any observed or suspected violation of patient/resident rights consistent with
facility policy and procedure.
3. Be alert to, and report, any suspected or observed abuse or neglect of patient/resident, family/
significant other, visitors, co-workers or employer consistent with facility policy and procedure.
4. Be alert to, and report per facility policy and procedure suspected or observed fraudulent
documentation by co-workers or employer.
5. Be alert to, and report per facility policy and procedure suspected or observed diversion or abuse of
controlled substances or other medications by co-workers or employer.
6. Acknowledge the multicultural customs and values of patient/resident, family/significant other, other
members of the health care team, and the employer.
7. Refrain from taking advantage of the professional relations for personal gain, i.e. with vendors, co-
workers, patient/resident, and family/significant others.
8. Utilize basic communication skills to resolve conflict by:
a. Utilizing appropriate actions and language to clarify and resolve disagreements with
patient/resident, family/significant other, facility employees and administrative personnel, and
physicians.
25
b. Seeking clarification regarding areas of dispute or concern from the administrator as
appropriate.
9. Maintain confidentiality of patient/resident information.
10. Demonstrate courteous behavior to patient/resident, family/significant other, co-workers, other
members of the health care team, and the employer.
