Job Summary

• Identifying each resident’s social, emotional and psychological needs

• Developing and carrying out a plan to develop the resident’s full potential during their stay
• Educates patient/family regarding post-acute options and addresses issues of choice
• Assists team members with discharge planning activities

Core Responsibilities:

• Complete and document Social Work and Psychosocial assessments for all residents within 3 days of their admission or re-admission.
• Ensure 3877/78 forms are completed and accurate, upon admission and annually.
• Ensure all new admissions and re-admissions have a scheduled 72 hour Resident Care Conference. Additionally, you will notify the IDT by email of date, time, resident and if family will be attending. This goes for quarterly and annual Resident Care Conferences as well.
• Complete MDS sections and the appropriate CAA’s.
• Completes, reviews and updates Care Plans including, Psychosocial, Discharge Planning, Behavioral, Cognitive loss, mood, vision, hearing Podiatry, dental. Ensures diagnosis, and medications are accurately captured on the resident’s care plans.
• Monitor the behavior log book and follow up on any new or changed behaviors noted.
• Monitor high risk residents including but not limited to:
  • Psychiatric dx. And/or medications
  • Age 55 or under
  • Residents with communication barriers
  • Non-verbal residents
• Attend the weekly Medicare Meeting
• Attend the monthly QAPI meeting and have all your data prepared to speak on. Remember to separate your lists into short and long-term residents.
• Coordinate care with the psych provider including medication management, medication consents, GDRs.
• Coordinate all ancillary services, Dental, Ophthalmology, and Audiology the resident may need or request with the input of the DON and/or Administrator.
• Educates residents & families related to Advanced Directives, completes the Advance Directive and Code Status form within 48 hours of admission.
• Greets Residents, families, etc, introduces self, and identifies purpose for visit
• Ensures daily visits and assessments x 3 days for any resident involved event including documentation.
• Documents all interactions with residents, families, Health Care Providers etc in the Medical Record.
• Demonstrates proficiency with EMR for facility.
• Handles problems of adjustment to the facility environment and maintains frequent contact with residents & families.
• As needed may be involved in in-service training of aides and staff related to resident rights and Social Services.
• Effectively and thoroughly answers patient and family questions
• If a hospice referral indicated, coordinate care with provider.
• Begins discharge planning for residents on admission & ongoing, working with all aspects of the interdisciplinary team to ensure an appropriate/safe resident discharge.
• Provide resident/family with written information about the resident rights related to discharge including the appeal process.
• Arranges DME & Home Care for residents at time of discharge.
• Establishes working relationships with community health, welfare and volunteer groups to promote cooperative assistance in meeting social needs of residents & families.
• Demonstrates kind, caring demeanor with resident, family and staff interactions.
• Other duties as requested

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Minimum Qualifications

• Bachelor's degree in social work – or – a Bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, gerontology and psychology required

• 1 year of supervised social work experience in a health care setting working directly with individuals required