Provides social services support to meet the psychosocial needs of our residents in the Health Center (Skilled Nursing Facility) and their family members. Proactively manages residents’ care by enhancing residents’ abilities to achieve highest level of independence, functioning, and satisfaction. Offers social services support to the Memory Care Unit’s residents by providing psychosocial assessments that contribute to comprehensive service plans.
• Identifies, evaluates, and documents the psychological needs of the residents and develops a written plan to meet those needs either directly or through referral sources.
• Ensures social services assessments and care plans are developed, documented, and reviewed at least quarterly. Completes assigned sections of the MDS (Minimum Data Set) accurately and timely.
• Functions as an effective member of interdisciplinary team to contribute to a comprehensive care planning process. Informs Nursing and other departments when residents experience a psychological change of condition. Coordinates schedule of care conferences.
• Advocates on the residents’ behalf to ensure the active promotion of resident rights. Informs residents/families of change in rules, regulations, and/or facility’s routine. Provides one-on-one counseling to residents to address individual concerns as required. Acts as liaison between residents and other departments. Complies with HIPAA privacy procedure to assure resident rights are protected and maintains confidentiality.
• Assists residents and families with emotional adjustment to life in long-term care facility. Utilizes the ability of each resident to guide him/her to a self-determination lifestyle that provides a degree of satisfaction within the nursing and rehabilitation environment. Involves residents and families in the care planning process. Provides crisis intervention for residents and families when appropriate.
• Provides oral and written information about facility and admission policies to interested parties; takes prospective residents and families on tours. Participates in admission process including securing a copy of the Advance Directive and orienting residents on their rights and the facility’s services.
• In collaboration with interdisciplinary team (IDT), physician, residents, and/or families, ensures resident discharge process. Organizes and makes appropriate arrangements for discharge planning, including preparation of all necessary documentation, coordination of post-discharge home health, long-term care, and post-discharge equipment (DME). Safeguards appropriate and timely transition to other levels of care for the community’s residents following the CCRC Resident Transfer Grounds and Process protocol.
• Plans, develops, organizes, implements, and evaluates the social service programs in the Health Center (Skilled Nursing unit). Coordinates social service activities with other departments. Makes written and oral recommendations concerning the operation of the social services program.
• Identifies potential risk management problems before they escalate into crises and keeps Administrator informed in all areas of resident rights, grievances, complaints, safety, liability, and any other issues.
• Maintains an involved community profile, especially with service provides, referral agencies, medical communities, and government agencies. Educates families in all matters related to the Social Services programs. Maintains and utilizes a comprehensive community resources file to meet specific needs.
• In collaboration with Activity department, assures that resident/family councils are held according to company policy. Coordinates self-support groups to enable residents and families to promote their own well-being and create a support structure within the Health Center unit.
• Coordinates Advance Directive and/or POLST follow-up process in the Health Center.
• Coordinates room and roommate changes. Acts as the community’s designee for the Health Center family and residents Customer Grievance and Theft/Loss procedures per facility policy and maintains logs to ensure CARF-CCAC conformance and regulatory compliance. Safeguards residents’ property per facility policy. Provides one-on-one counseling to residents to address individual concerns.
• Investigates and documents allegations of abuse. Provides in-service education on topics such as abuse reporting, resident rights, social and emotional needs of the residents and families, and the mission of the social services program.
• Fosters a climate of outstanding customer service. Plays a key role in the Environmental/Safety rounds to help ensure resident self-determination, dignity, and choices.
• Attends continuing educational programs designed to keep abreast of changes in the profession.
• Completes all documentation and other requirements according to regulations and company policy. Participates in survey (inspections) made by authorized government agencies, and develops a plan of correction for social service deficiencies noted during survey inspections.
• Participates in the Quality Assurance and Performance Improvement Process by serving on committees, developing and implementing appropriate plans of action to correct identified deficiencies, providing written and/or oral reports of the social service programs and activities, and evaluating/implementing recommendations from established committees.
• Serves as Psychotropic Committee’s co-chair to ensure psychotropic and behavior management procedures are in compliance.
• Performs other duties as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED TO PERFORM ESSENTIAL JOB FUNCTIONS:
Demonstrated interpersonal, verbal, and written English communication. Knowledge of OBRA regulations, Title 22, and Division 5 and 6 California Administrative Code. Knowledge of and access to community resources. Knowledge of and willingness to discover programs and services appropriate for residents. Knowledge and understanding of advance directives and possesses the ability to counsel residents and responsible parties on obligations of being a Durable Power of Attorney Health Care Agent. Instructional skills to present information. Organizational skills to document notes and maintain logs. Sound judgment skills to assess needs and determine appropriate course of action in emergency situations. Awareness and judgment skills to recognize changes of residents’ conditions. Proficient with Microsoft Office suite of products (Word, Excel, Outlook) and the ability to quickly learn clinical software programs and the use of a smartphone. Ability to interpret complex laws, regulations, and policies. Ability to meet project deadlines and to be productive in a high volume, high stress environment. Ability to act with patience, tact, and courtesy in dealing with residents, their families, staff, and vendors under demanding and difficult conditions. Sensitivity and understanding of issues related to aging, bereavement, grief, and loss. Physical skills and ability to perform work that requires sitting, walking, stooping, bending, and lifting up to 35 pounds.
Bachelor Degree in Social Work or related fields is required. Social Service certificate is preferred. Minimum of three (3) years’ experience in a long-term care setting is required. Three to five years of post-acute care experience or skilled-nursing facility (SNF) experience as a SNF social worker or SNF discharge planner is highly preferred.