The social worker will work with residents in the skilled nursing facility by identifying their psychosocial, mental and emotional needs along with providing, developing, and/or aiding in the access of services to meet those needs. Services will be provided in accordance with the National Association of Social Workers (NASW) Code of Ethics along with strict adherence to government regulations. The nursing home social worker is responsible for fostering a climate, policies and routines that enable residents to maximize their individuality, independence and dignity. This climate shall provide residents with the highest practical level of physical, mental and psychosocial well-being and quality of life.

Guiding Principles

Social work services in long-term care settings focus on several key areas, including the social and emotional impact of physical or mental illness or disability, the preservation and enhancement of physical and social functioning, the promotion of the conditions essential to ensure maximum benefits from long-term health care services, the prevention of physical and mental illness and increased disability, and the promotion and maintenance of physical and mental health and an optimal quality of life.

Objectives

• providing direct social services to residents and their families by professionally trained social workers.

• assisting residents and families to use and receive maximum benefit from the facility and community-based social and health resources on a continuum throughout the stay of each resident

• strengthening communications among residents, families, and the program or facility staff

• assisting the facility to achieve and maintain a therapeutic environment essential to the optimal quality of life and independent functioning of each resident and to provide for maximum participation of residents in planning activities and policies.

Standards for Social Work Services in Long -Term Care Facilities

Ethics and Values

Social workers in long-term care facilities shall demonstrate a commitment to the values and ethics of the social work profession, emphasizing resident empowerment and self-determination, and shall use NASW's Code of Ethics (2000) as a guide to ethical decision making.

Service Plan

The long-term care facility shall maintain a written plan for defining social work services designed to ensure their availability to all residents and their families. The plan for social work services shall be guided by a written statement of philosophy, objectives, and policies.

The plan shall include, but not necessarily be limited to, the following:

• communication and collaboration with the care plan team and others involved with residents' care

• collaboration with colleagues, community agencies, volunteers, and consultants

• development and implementation of services and special programs

• compliance with laws and regulations mandated by federal, state, and local governing bodies

• requirements for professional development and continuing education of social work staff

• maintenance of residents' medical records and reports mandated by federal, state, and local laws and the facility.

Responsibilities of Work Department

Carry primary responsibility for social work services, including the development of organizational plans and administrative policies and procedures and coordination of services. The social work coordinator responsibilities may include the following:

• development and implementation of all social health programs

• implementation and oversight of procedures to ensure that adequate documentation of social work services is provided in each resident's medical record and that legal, ethical, and professional standards are observed in written recordings

• establishment and administration of a social work program that provides high-quality care and services reflective of professional standards of practice and in compliance with all federal, state, and local laws

• establishment and administration of quality assurance procedures and modification of these procedures where appropriate

• ensuring that staff is knowledgeable about residents' rights in accordance with all federal, state, and local laws.

Program Functions

The functions of the social work program shall include, but not be limited to, direct services to residents, families, and other individuals involved with residents' care; advocacy; care planning, discharge planning and documentation; participation in policy and program planning; quality improvement; staff education pertaining to social services; liaison to the community; and consultation to other staff members.

Specific social work functions may include, but are not be limited to, the following:

• preadmission services, including biopsychosocial assessments and participation in interdisciplinary evaluation of the individual's need for institutional care and preparation of the incoming resident identification of needs and coordination of services to ensure that the biopsychosocial needs of each resident are met

• participation in the development and reassessment, as needed, of individualized social service and interdisciplinary care plans designed to meet the biopsychosocial needs of each resident

• assisting residents and families in locating and using financial, legal, mental health, and other community resources

• provision of individual, family, and group services focused on the maintenance or enhancement of the resident's biopsychosocial functioning and understanding of the resident's placement and health status; services may include assistance with the following: concerns related to the resident's illness, disability, treatment, financial and medical decision making; placement and expectations of care; inter- or interfaculty transfers; interpersonal relationships; re-establishing community living; and coping with separation, loss, dying, and death advocacy of appropriate care and treatment of residents through the development and implementation of policies, and the education of residents, staff, and family regarding residents' rights, as well as consultation with the long-term care ombudsperson

• ensuring that health and mental health social work services are available to residents to assist with attaining or maintaining the highest practical mental and psychosocial

wellbeing, while helping residents who display mental or psychosocial difficulty receive appropriate treatment and services

• acting as a resource to staff participating in behavioral interventions facilitating residents' safe integration into the community through interdisciplinary discharge planning and follow-up services

• participation in planning and policy development for the facility, including collaboration with other members of the staff in the identification of biopsychosocial, cultural, and environmental factors essential to the delivery of quality care to residents and families, participation in orientation of all new employees, and in-service training of facility personnel

• participation in resident and family council development, as needed or requested

• participation with medical personnel and facility staff in discussing with competent residents and families advance directives and financial powers of attorney; for incompetent residents, participation in discussions of guardianship and surrogate decision making

Documentation

Documentation of social work services provided to residents, family members, and other individuals involved with the resident's care must be recorded in the medical record.

Progress notes and other social work entries in the medical record shall be recorded to permit and encourage regular and ongoing communication with physicians and other professionals involved in the resident's care.

Cultural Competence

Social workers shall provide residents and their families with social services in the context of multicultural understanding and competence.

The increasingly diverse population in the United States requires that social workers raise their awareness and appreciation of cultural differences. Social workers must develop competencies that include heightened self-awareness, knowledge, and practice skills consistent with the NASW Standards for Cultural Competence in Social Work Practice (NASW, 2001).

Work Environment

There should be adequate budget, space, facilities, and equipment to fulfill the professional and administrative needs of the social work program.

Offices of the social work staff must be readily accessible to residents, their families, and facility staff. They should provide privacy and confidentiality for individual, family, and group work; conferences; telephone calls; and documentation. Standard office equipment that adequately reflects current office technological needs should be provided.

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