Social Service Designee

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SOCIAL SERVICE DESIGNEE Skilled Nursing Facility / Assisted Living Facility

Position Summary The Social Service Designee is responsible for providing social services to residents and families in a skilled nursing or assisted living facility that does not employ a licensed or degreed social worker as required by state staffing thresholds. Under the direction of the Administrator, the Social Service Designee performs the core social services functions of the facility including psychosocial support, discharge planning, advance care planning, resident rights advocacy, and connection to community resources. This position is most commonly found in facilities with fewer than 120 licensed beds in Indiana where a licensed social worker is not mandated by state regulation. The Social Service Designee is not a licensed social worker and must operate within the boundaries of their training, experience, and facility-defined scope of responsibility.

Key Responsibilities

Psychosocial Support & Resident Interaction

• Build and maintain supportive, trusting relationships with all residents through regular rounding, one-on-one visits, and genuine interest in residents' emotional and social well-being

• Identify residents who appear depressed, anxious, withdrawn, isolated, or distressed and bring concerns to the Administrator or attending physician promptly

• Provide basic emotional support and active listening to residents and families navigating adjustment to placement, grief, loss, or difficult life transitions

• Assist residents in maintaining connections with family, friends, and the broader community through facilitated visits, phone calls, and written correspondence

• Support residents in adjusting to the facility environment at admission including orientation to the building, introduction to staff and other residents, and explanation of daily routines and available services

• Refer residents with identified mental health needs to the attending physician or outside mental health provider for further evaluation and treatment

• Participate in resident council meetings and bring resident concerns and suggestions to the appropriate department heads and administration

Admission & Intake

• Participate in the admission process including completing the social history, gathering information about the resident's background, interests, family relationships, and psychosocial needs

• Explain the facility's admission documents to residents and families including the admission agreement, financial disclosure, resident rights, and grievance procedures

• Ensure all required admission paperwork is completed, signed, and filed accurately and within required timeframes

• Coordinate with nursing, dietary, housekeeping, and activities to ensure the facility is prepared for each new admission

• Complete the Level I PASARR screen on all new admissions and refer residents who meet criteria for a Level II evaluation to the appropriate state authority

• Gather and document advance directive status at admission and ensure existing documents are placed in the resident record and accessible to the clinical team

Discharge Planning

• Initiate basic discharge planning conversations with short-stay residents and families early in the admission

• Identify the resident's discharge goals, anticipated living situation, and basic post-discharge service needs

• Assist with coordinating straightforward post-discharge services including home health referrals, transportation arrangements, and durable medical equipment orders under the direction of the Administrator or attending physician

• Communicate discharge plans to the nursing team, attending physician, and family in a timely manner

• Refer complex discharge planning situations including unsafe home environments, lack of caregiver support, housing instability, or residents without decision-making capacity to the Administrator or an outside social work consultant

• Complete required discharge documentation per facility policy and CMS requirements

Advance Care Planning

• Discuss advance directive options with residents and families at admission in a supportive and non-coercive manner

• Assist residents in completing or updating advance directives including living wills, healthcare representative designations, and POLST forms per Indiana law and facility policy

• Ensure advance directive documents are accurately documented in the resident record and communicated to the nursing team

• Review advance directive status at admission, with any significant change in condition, and annually per facility policy

• Refer advance care planning situations involving conflict between the resident, family, and physician to the Administrator or attending physician for resolution

Resident Rights & Advocacy

• Protect and promote resident rights in all interactions and facility processes in accordance with CMS F-tags F550–F600 and Indiana resident rights statutes

• Educate residents and families on resident rights, the facility grievance process, and the role of the Indiana Long-Term Care Ombudsman at admission and throughout the stay

• Receive, document, and assist in resolving resident and family grievances under the direction of the Administrator

• Assist residents in contacting the Long-Term Care Ombudsman or filing complaints with the Indiana State Department of Health (ISDH) if requested

• Report all allegations of abuse, neglect, exploitation, and misappropriation of resident property to the Administrator and appropriate authorities per Indiana mandatory reporting requirements and facility policy

• Assist residents who lack a legal decision-maker by bringing guardianship or conservatorship concerns to the Administrator for referral to legal counsel

Community Resources & Financial Assistance

• Maintain working knowledge of local and state community resources available to residents and families including Area Agency on Aging, Indiana Medicaid (IHCP), Veterans benefits, hospice providers, mental health agencies, legal aid, and transportation services

• Assist residents and families with identifying and applying for financial assistance programs including Indiana Medicaid, Veterans benefits, and supplemental insurance under the direction of the Administrator and Business Office

• Connect residents and families with appropriate community resources to support discharge planning, family caregiving, and post-discharge needs

• Maintain a current community resource directory and update it regularly

Documentation & Regulatory Compliance

• Complete and maintain accurate, timely, and confidential social service documentation in the electronic health record (EHR) or resident record per CMS and ISDH requirements

• Contribute to MDS social service sections including Section E, F, and Q in collaboration with the MDS Coordinator within required timeframes

• Ensure social service documentation meets CMS Conditions of Participation requirements for social services (F740–F746)

• Assist in preparation for annual ISDH surveys related to social services; respond to social service findings and Plans of Correction under the direction of the Administrator

• Participate in QAPI meetings and contribute social service observations, concerns, and improvement suggestions

• Complete required PASARR documentation accurately and within required timeframes

Family Support & Communication

• Serve as a warm, informative, and accessible point of contact for resident families regarding social service concerns, care transitions, and community resources

• Facilitate basic family communication and assist in scheduling family meetings with the interdisciplinary team

• Notify families of significant changes in resident condition, transfers, hospitalizations, and deaths per facility policy and CMS requirements

• Provide basic information and support to families navigating the long-term care system, financial concerns, and caregiver stress

• Maintain professional boundaries while providing genuine compassion and support to residents and families in difficult situations

Interdisciplinary Collaboration

• Participate in interdisciplinary care conferences and contribute social service observations and resident and family input to care planning decisions

• Collaborate with nursing, dietary, therapy, activities, and housekeeping to address resident psychosocial needs and quality of life concerns

• Attend and contribute to department head meetings as requested by the Administrator

• Communicate resident and family concerns to the appropriate department head or Administrator promptly and follow up to ensure resolution

Qualifications

• High school diploma or GED required; associate or bachelor's degree in human services, psychology, sociology, gerontology, or a related field preferred

• Prior experience in a social service, human services, case management, or long-term care setting preferred

• Completion of state-approved or facility-provided social service designee training strongly preferred

• In Indiana — facilities under 120 licensed beds are not required to employ a licensed social worker under ISDH regulations (410 IAC 16.2); the Social Service Designee must be qualified by training and experience to perform the social services function as defined by CMS

• Familiarity with Indiana resident rights statutes, Indiana mandatory reporting requirements, and Indiana advance directive documents preferred

• Knowledge of local and state community resources available to long-term care residents and families

• Strong interpersonal, communication, and organizational skills

• Genuine compassion for elderly and medically complex residents and their families

• Ability to maintain confidentiality and handle sensitive information with discretion and professionalism

• Proficiency with basic computer skills and electronic health record documentation preferred

Physical Requirements

• Primarily office and facility floor-based with regular resident and family interaction throughout the building

• Ability to move throughout the facility for resident visits, care conferences, and family meetings

• Occasional lifting of files, office supplies, or resident belongings up to 20 lbs

• Ability to respond calmly and effectively in emotionally sensitive or crisis situations

Reports To: Administrator / Executive Director

Benefits for Full Time Staff

• Health Insurance

• Life Insurance

• AD&D Insurance

• Vision Insurance

• Prescription Drug Coverage

• Disability Insurance

• Dental Insurance

• KISx Card (surgery and imaging program)

• Flexible Spending Account (FSA)

• 401K w/matching

• PTO

• Tuition Reimbursement

• Daily Pay Available (receive half your pay immediately, each day you work)