Demo

Social Worker

Focused Post Acute Care Partners
Fort Stockton, TX Full Time
POSTED ON 9/25/2025
AVAILABLE BEFORE 10/24/2025
## Description

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Focused Post Acute Care Partners FPACP is a dynamic company with an expectation of excellence in the delivery of long-term care to every patient every day. We are looking for a Social Worker to join our great team!

At FPACP, we take pride in our culture and ROCKIN recognition program ROCKStar (Recognizing Outstanding Care and Kindness). This program is used across the organization for team members, residents, family members, volunteers, and business partners. The gamification component is a fun and competitive way team members level up monthly, getting one step closer to attending the annual FPACP Gala. Apply to find out more and become our next ROCKStar.

Position Summary

As 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

  • 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 or obtain within 6 months of hire.
  • Prefer two (2) years of experience in long-term care, hospital, or other related medical facilities.
  • Able to react to emergency situations appropriately when required.

Essential Functions

Meet with administration, medical and nursing staff, and other related departments in planning social services.

Advocate 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.

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.

Educate, review and assist 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 information to the agency providing the service (Optometry, Audiological, Dental, Podiatry, Counseling, Psychiatry, Psychological testing) on behalf of the residents.

Educate/ communicate with residents and/or responsible parties about Palliative Care vs. Hospice Care and assist 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.

Assist with scheduling transportation for residents to medical appointments.

Prepare a Social Service Evaluation prior to each resident's care plan to assess changes / areas of need since their last care plan.

Document 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.

Prepares care plans including: Advance Directives, DNR, resident personal preferences, behavioral/psychosocial issues.

Facilitates resident room changes including five-day elocation notice, follow-up with resident, responsible party, roommate, physician, and nursing and documentation of aforementioned process.

Reviews resident's psychosocial wellbeing due to loss of a family member, friend, or roommate.

Attends Resident Council meetings only if

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