RESPONSIBILITIES:As a licensed Social Worker, we will rely on your knowledge of resources available in the community as well as your experience and judgment to act as a primary referral source to members. You will interview, coordinate and refer members to resources that have been identified and promote activities that will help the member to meet their social and emotional needs and, when appropriate, their families. You must be familiar with standard concepts, practices and procedures within the field

QUALIFICATIONS:

• Ideal candidate must be a skilled communicator, director and motivator; able to organize and prioritize many tasks effectively
• Prefer two (2) years of experience in a long term care, hospital or other related medical facility
• Able to react to emergency situations appropriately when required
• Bachelor’s Degree in Social Work or a Human Services field including, Sociology, Gerontology, Special Education, Rehabilitation Counseling, and Psychology.
• Must be a licensed Social Worker in the state of Texas

ESSENTIAL FUNCTIONS:

• To assure resident safety.
• Meet with administration, medical and nursing staff and other related departments in planning social services
• Advocates daily on behalf of all residents to ensure that their rights are maintained
• Reports abuse, neglect or exploitation per state reporting guidelines
• Maintains professional working rapport with facility interdisciplinary team and community resources/agencies
• Consistently abides by Social Work Code of Ethics and strives to represent Senior Care Centers by exhibiting professionalism and quality work
• Completes Social Service History and Social Service Evaluation with newly admitted residents within 14 days
• Completes sections “B, C, D, E and Q" of MDS 3.0 on days 5, 14, 30, 60, 90, annually, upon change of condition and upon resident readmission from hospitalization
• Educates, reviews and assists residents in completing Advance Directives, Medical Power of Attorney, Out of Hospital Do Not Resuscitate documents
• Facilitates referrals to ancillary services including: Follow up with the resident and their responsible party, requesting/obtaining physician orders, copying and faxing informationto the agency providing the service (Optometry, Audiological, Dental, Podiatry, Counseling, Psychiatry, Psychological testing) on behalf of the residents
• Educates / communicates with residents and/or responsible parties about Palliative Care vs. Hospice Care and assists in the referral / transition process of residents to end of life services and end of life decision making
• Procures prior authorization numbers for residents with Medicaid who require ambulance transportation to non-emergency medical appointments
• Assists with scheduling transportation for residents to medical appointments
• Prepares a Social Service Evaluation prior to each resident’s care plan to assess changes / areas of need since their last care plan
• Documents interactions with residents and/or responsible parties that are reflective of assessments performed, assistance provided and issue resolution
• Discharge preparations with residents and/or responsible parties throughout stay in facility to culminate all community services requested /required
• Discharge planning on behalf of residents including: requesting/obtaining appropriate physician orders, communication and follow up with community resources (Home Health Agency, Equipment Company, Primary Care Physician, Hospice Agency, CBA Agency, Transportation Agency, Meals on Wheels Agency, Support Groups etc.,) copying pertinent information from resident’s chart to forward to agencies that require it in order to bill for services. Preparation and review of Discharge Instructions for Care with the resident and responsible party. Documentation of all discharge planning. Follow up with resident and responsible party post discharge to ensure that resident’s transition back into the community was as seamless as possible
• Prepares care plans including: Advance Directives, DNR, resident personal preferences, behavioral / psychosocial issues
• Facilitates resident room changes including: five day relocation notice, follow up with resident, responsible party, roommate, physician and nursing and documentation of afore mentioned process
• Reviews resident’s psychosocial wellbeing due to loss of a family member, friend or roommate
• Attends Resident Council meetings only if invited by the Council members and assists in resolution of any issues presented
• Facilitates proper procedure on initiation / completion of Grievance Reports and assists in maintaining the facility Monthly Grievance Log
• Attends and provides quarterly information for Performance Improvement / Quality Assurance meetings including: all resident referrals made in last quarter, all behavioral issues addressed / resolved in last quarter, tracking and trending of grievances within the facility during last quarter
• Attends Standards of Care meetings and follows up on any Social Work issues discussed
• Performs bi-annual reviews of all resident charts to ensure that assessments, documentation, directives and care planning are current, consistent and appropriately placed in the chart
• Maintains knowledge of federal and state regulations for long-term care facilities
• Develop and maintain a good working rapport with intra-department personnel, other departments within the facility and outside community health, welfare and social agencies to ensure that social service programs can be properly maintained to meet the needs of the patients / residents
• Keep up to date with current federal and state regulations as well as professional standards, and make recommendations on changes in policies and procedures to the department director or Administrator