Social Service Designee

The Social Service Designee is responsible for assisting in the development, implementation, and coordination of psychosocial services for residents in the skilled nursing facility. This role ensures that residents attain or maintain their highest practicable level of physical, mental, and psychosocial well-being in accordance with federal and state regulations.

Key Responsibilities
1. Psychosocial Assessment & Care Planning

• Complete psychosocial assessments upon admission and as required by regulation.
• Participate in the Minimum Data Set (MDS) process, including relevant sections related to mood, behavior, and discharge planning.
• Contribute to the development and ongoing review of person-centered care plans.
• Monitor residents’ psychosocial status and document significant changes.

2. Resident & Family Support

• Provide emotional support and counseling to residents and families.
• Assist residents in adjusting to placement within the facility.
• Facilitate communication between residents, families, and the interdisciplinary team.
• Coordinate family meetings and care conferences as needed.
• Advocate for resident rights and preferences.

3. Discharge & Transition Planning

• Coordinate safe and appropriate discharge plans in collaboration with the interdisciplinary team.
• Arrange community resources, home health services, durable medical equipment, and transportation.
• Ensure compliance with CMS discharge planning requirements.
• Provide residents and families with education regarding post-discharge services.

4. Resident Rights & Grievance Management

• Educate residents and families on resident rights.
• Assist in the investigation and resolution of grievances.
• Maintain documentation of complaints and follow-up actions.
• Support residents in accessing advocacy services such as the Long-Term Care Ombudsman.

5. Behavioral & Mental Health Support

• Identify residents with behavioral health or psychosocial needs.
• Coordinate referrals to mental health providers or community agencies.
• Assist with behavior management strategies and interventions.
• Support residents experiencing grief, loss, or end-of-life transitions.

6. Coordination of Services

• Collaborate with nursing, therapy, dietary, activities, and medical staff to ensure holistic care.
• Assist with Medicaid and other financial resource applications when appropriate.
• Coordinate room changes and assist with admission and transfer processes.
• Maintain relationships with community agencies and service providers.

7. Documentation & Compliance

• Maintain accurate, timely, and compliant documentation in the electronic health record (e.g., PointClickCare).
• Ensure all social service documentation meets regulatory and facility standards.
• Participate in Quality Assurance and Performance Improvement (QAPI) initiatives.
• Assist with survey preparedness and provide documentation during regulatory inspections.