SUMMARY

The Social Worker will assess and identify the needs of newly admitted residents in order to do adequate discharge plans and to offer the highest practical level of physical, mental and psychosocial well-being and quality of life within the facility and upon discharge. He/she will work with other staff to develop and continually evaluate/update a plan of care, document progress and assure that standards of care are being met. The Social Worker will have input in development of policies and procedures to assure that individuality, independence and dignity are addressed. The Social Worker will work with the Administrator in developing and updating department policies and procedures to reflect the latest best practices and regulations.

ESSENTIAL DUTIES AND RESPONSIBILITIES

The duties of the Social Worker include, but are not limited to:

• Interface with nursing office, MDS Coordinator, Therapy Manager and other staff in forming and reviewing the care plan and discharge plan.
• Interview the resident and involved family members to identify the responsible party and care givers necessary for smooth discharge. Works with nursing staff for smooth discharge and utilization of preferred agencies/providers.
• Interview the resident and responsible parties to identify areas that need to be addressed in order to provide the best quality of life within the resident’s means and resources.
• Begins discharge planning upon admission to community or most appropriate setting by conferring with the resident, nursing staff, medical staff and community resources. Identifies preferences and resources for care in the community in order to facilitate smooth discharge.
• Attends daily staff meetings in order to facilitate care and services to current and new residents.
• Initiates and correctly completes assessment according to federal and state guidelines on admission, quarterly and annually and complete according to RAI manual. Correctly and timely completes all portions of the assessment for which they are responsible.
• Assists residents with room placement and room changes as appropriate, honoring preferences when possible.
• Is responsible for coordinating admissions in the absence of the Admissions Coordinator, including keeping the referral/wait list updated.
• Serves a chairperson of the Grievance Committee if a grievance is filed. Works with other staff and Administrator to address complaints and grievances in order to avoid repeat complaints or escalation of dissatisfaction. Assists in investigating abuse allegations and unusual occurrences, missing items.
• Responsible for communicating written Medicare/CMS notifications to Responsible Party within federal guidelines for timely notices.
• Maintains a current list of community resources and agencies which offer services upon discharge.
• Practices advocacy for the resident and promotes “aging in place” by referring to home and community services that give the resident as much choice as possible within their means and community support.
• Participates in and maintains highest level of professional training on software used for documentation.
• Keeps up knowledge of current and changes in Medicare regulation requirements as well as civil money penalties for false information. Stays knowledgeable on federal and state requirements for social services documentation.
• Interfaces with MDS staff to assure communication on certification or re-certification for managed care coverage.
• Develops and maintains a good working rapport with other departments with the facility.
• Consistently demonstrates professionalism and confidentiality.
• Participates in quality assurance program and attends appropriate QA committee meetings
• Serves on other committees as requested.
• Attends all mandatory in service including annual fire, OSHA and CDC program.
• Cross trains on Admissions Coordinator, using current policies, procedures and job description to cover resident admissions when the Admissions Coordinator is on leave. Provides Admissions Coverage when Admissions Coordinator is on leave.
• Practices in adherence to national standards for electronic health care transactions and code sets, unique health identifiers, and security, including passwords and user ID codes, in compliance with the Privacy Act and HIPAA. Notifies Administrator, or Director of Nursing in the absence of the Administrator, of any known violations.
• The Social Worker may be called upon to work occasional weekends in a managerial rotation.
• Renders all services without discrimination regarding race, color, national origin, sex or handicapping condition.
• Must pass drug screen and background check.

EDUCATION and/or EXPERIENCE

A 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, and psychology; and, has had at least one year of supervised experience in a skilled nursing facility .