Job Summary:
Provides psychosocial assessment and appropriate counseling, support, resources, and educational interventions for residents / patients.
Documents assessment data on MDS and progress notes.
Participates in care planning and care conferences.
Coordinates discharge planning.
Assists residents / patients and families with personal needs and services not provided by nursing staff.
Advocates for residents / patients rights assuring that rights are respected by staff and others.
Qualifications:
Bachelor’s degree in behavioral science field.
One year experience in social services in a skilled nursing facility.
Duties and Responsibilities:
Provide social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident / patient.
1) Complete a social service history for all newly admitted residents and patients within 14 days of admission.
Complete a progress note for all new residents and patients and those readmitted from the hospital within seven days.
2) Complete a new PASRR for patients who transfer to long-term care.
3) Complete section A, E, Q, R of the MDS with RAPs for E, as needed.
4) Care plan mood, behavior, and psychosocial needs with appropriate staff and / or support service.
5) Complete quarterly, change of condition, and annual social services progress notes.
6) Reassess resident / patient care plans at least quarterly, updating problems, goals, and approaches as necessary and reassessing discharge plans.
7) Participate in interdisciplinary team care conferences for all residents and patients: Within 21 days for new admissions and on a quarterly basis thereafter.
8) Coordinate discharge or transfer planning with resident or patient, family or responsible party, physician, staff, home health, and other community agencies.
Make referrals for transportation, meals, dialysis, in-home assistance, oxygen, durable medical equipment and supplies, placement.
Complete Medicare discontinuation letter and distribute.
9) Identify changes in responses, behavior or personality, such as depression, anxiety, withdrawal or aggression and discuss with the interdisciplinary team.
Chart
10) Counsel residents, patients, and families in support of adjustment facility, changes in health, rehabilitation and expectations, and the dying process.
11) Respond to crisis situations.
Consult and / or act as liaison and advocate regarding issues such as safety, alleged abuse, room mate dispute, elopement.
12) Educate residents, patients, families, and staff on concepts of aging, emotional effects of loss and change, communication dynamics, dementia, and mental illness.
13) Administer MMSE and depression assessments for purposes of care and discharge planning.
14) Educate residents, patients, and families about ALTCS and facilitate or make application as appropriate.
Refer to elder law attorneys for complex cases.
15) Assist residents, patients, and families with medical and / or financial powers of attorney and advanced directives
16) Assist business office with payor source information and / or reimbursement problem identification and resolution as appropriate.
17) Refer residents and patients to hospice as appropriate.
18) Manage and coordinate the Lost Item protocol and search procedures for the facility.
19) Assist with resident and patient needs for transportation, clothing, glasses, dentures, hearing aides, and other assistive devices.
20) Maintain a file of community resources and make referrals to provide resources as needed.
21) Stay current with facility, state, and federal regulations, policies, and procedures as they apply to social services.
22) Facilitate and convene Family Council as needed or requested by families.
23) Attend and participate in staff meetings, department head meetings, rehab meetings, and continuous quality improvement.
24) Other responsibilities as assigned.
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