Social Worker responsibilities: creating a therapeutic environment to promote independent functioning; maintaining residents at or restoring residents to an optimal level of functioning; providing for the highest level of well-being; and allowing for maximum participation by the resident, the family, and staff involved with residents’ care.

§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.

The social work director, in collaboration with other clinical and administrative representatives, is responsible for ensuring that the social work plan is implemented. The plan of the social work department shall provide procedures to ensure that all federal, state, and local laws are implemented and adhered to and shall be consistent with the facility’s policies and regulations.

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.

Entries by social work personnel shall include information related to the social and emotional functioning of the resident; relevant historical information regarding the resident and family and others involved with the resident’s care; psychosocial assessments; the social work plan and specific goals; services provided and outcomes; and a summary of problems and goals attained, as well as reasons for non-attainment of goals. Referrals to other agencies or resources should be documented in the resident’s medical record and should include any ongoing follow-up or recommendations by an outside agency or individual. Notes should be clear and concise.

Progress notes, reports, and summaries of services shall be regularly recorded in the medical record and be consistent with all federal, state, and local legal and statutory, regulatory, and policy requirements and with the organizations or facility’s policies on reporting, maintenance of and access to records, and confidentiality.

Policies and procedures shall be developed and implemented to protect residents’ rights to privacy, including confidentiality of records and procedures for release of information to individuals, and relevant community agencies.

It is preferable that the social work director be a graduate from an accredited school or program of social work, have a minimum of two years postgraduate experience in long-term care or related programs, and meet equivalent state requirements for social work practice.