POSITION SUMMARY:

The primary purpose of your job position is to assist in planning, organizing, implementing, evaluating, and directing the overall operation of our facility’s Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Director of Social Services and/or Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis.

• Assist in planning, developing, organizing, implementing, evaluating, and directing the social service programs.
• Stay up to date with federal and state regulations, as well as professional standards, and make recommendations on changes in policies and procedures to the Administrator
• Participate in discharge planning, development and implementation of social care plans and resident assessments
• Interview resident and families to obtain social history
• Involve the resident/family in planning social service programs when possible
• Arrange transportation to other facilities when necessary
• Refer Resident/families to appropriate social service agencies when the facility does not provide the services or needs of the Resident
• Provide information to resident/families as to Medicare/Medicaid, and other financial assistance programs available to the Resident
• Coordinate social service activities with other departments as necessary
• Maintain and keep the sex offender log, and notify the appropriate parties as needed
• Report all discharges to the ombudsman office and other agencies as required (DOH)
• Assist in providing solutions for social and practical environmental problems including seeking financial assistance, discharge planning (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required.
• Evaluate social and family information and assist in determining plans for social treatment.
• Report social, psychological, and emotional needs of the resident/family to the medical staff, attending physician, and other resident care team members.
• Assist in developing preliminary and comprehensive assessments of the social service needs of each resident.
• Assist in developing a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident and the goals to be accomplished for each problem/need identified relating to mood, behavior, psychosocial wellbeing, discharge status, code status and smoking, if applicable.
• Review and revise care plans and assessments as necessary, at a minimum quarterly
• Encourage the resident and family to participate in the development and review of their plan of care.
• Ensure that social services components of the MDS are completed and signed in a timely manner
• Assist in the scheduling of care plans and assessments to be presented and discussed at each committee meeting
• Review nurses’ notes to determine if the social service care plan is being followed. Report problem areas to the DON
• Develop and maintain a good rapport with all services involved with the care plan to ensure that a team effort is achieved in developing a comprehensive plan of care
• Be knowledgeable of the resident’s rights, and responsibilities, including the right of refusal
• Maintain a written record of the resident’s complaints and/or grievances that indicates the action taken to resolve the complaint and the status of the complaint.
• Provide residents with information concerning resident rights, living wills, advance directives etc.
• Participate in resident/group council meetings as requested and provide support services to such council
• Coordinate ancillary services to residents including optometrist, audiologist, psychologist and dentist.
• Complete and deliver the necessary paperwork for residents who are being cut from Medicare A services. Maintain a file of these letters
• Complete all necessary paperwork, relating to Pre-Admission Screening/Resident Review -(PASRR) and state specific requirements for Medicaid payment
• Maintain and upload into PCC all applicable Level II PASRR documentation and ensure compliance with all recommendations.
• Work with emotional problems including assisting resident/family with anxieties and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death, and the need for institutional and specialized care.
• Maintain Resident Demographics information within PCC , review at least quarterly
• Report known or suspected incidents of fraud to the Administrator
• Attend and participate in continuing education programs designed to keep you up-to-date of changes in your profession, as well as to maintain your license on a current status.
• Orient the resident to the long-term care environment and facilitate adjustment upon placement.
• Ensure that resident’s wishes regarding medical and nursing care are honored
• Ensure the implementation of advanced directives within 72 hours
• Ensure room changes are communicated with the resident, the resident’s roommate and the resident’s guardian and/or responsible party. All room changes must be documented in the resident’s medical record (PCC) and updated on the bed board.
• All other duties as assigned by Administration.