Social Worker

Social Worker

Full Time, 8am-4pm, M-F

JOB SUMMARY:

The social worker works directly with residents to identify 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 CMS and NYS regulations along with strict adherence to facility policies. The social worker is responsible for fostering a patient centered care, policies and routines that enable residents to maximize their individuality, independence and dignity. This patient centered cared  Provides residents with the highest practical level of physical, mental and psychosocial well-being and quality of life.

 Essential Duties & Responsibilities:

1. Upon admission the social worker will complete a social history and psychosocial assessment for each resident that identifies social, emotional, and psychological needs.

2. Upon admission the social worker will determine the resident’s code status, will maintain advance directive paperwork/policies at all times ensuring 100% of facility wide accuracy, and will assist residents/representative in modifying advanced directives when desired. 

3. Participate in the development of a written, interdisciplinary plan of care for each resident that identifies the psychosocial needs/issues of the resident, the goals to be accomplished for those needs/issues, and the appropriate social worker interventions.

4. Facilitate Care Plan meeting with resident/family and interdisciplinary team admission quarterly, annually and significant changes.

5. Ensure or provide therapeutic interventions to assist residents in coping with their transition and adjustment to a long-term care facility, including their social, emotional, and psychological needs.

6. Ensure or provide support and education to residents/family members/significant others to assist in their understanding of placement and facility issues in addition to referring them to the appropriate services when the facility does not provide the needed services.

7. Act as staff liaison for resident counsel and family counsel groups.

8. Provide clinical interventions to address catastrophic events that occur during the resident’s stay in the facility.

9. Discharge planner by identifying residents discharge plans and coordinate the resident discharge planning process by making referrals for appropriate home care services prior to the resident’s return to the community.

10. Meet with and provide counsel and support to those residents with psychosocial needs, those that self-direct care in a manner that prohibits them reaching their highest practicable level of functioning, and those needing additional support and TLC.

11.  Provide a summary documentation no less than quarterly based on the MDS schedule. Such documentation shall be in the form of a progress note and shall be completed prior to completion of the MDS as assigned on the MDS schedule.

12. Completion of BIM’s, Mood, Psychosocial, Behavior, and Discharge observations timely and in accordance with established policies and guidelines

13. Complete sections of the MDS as assigned timely and accurately.

14.  Daily documentation on resident/representative interactions.

15.  Facilitate room-changes.

16.  Participate in QAPI including the completion and presentation of audits as assigned as well as the identification of issues related to resident wellbeing.

17.  Completing all required documentation in the medical record (EMR)

18.  Work collaboratively with members of all disciplines, internally and externally, to ensure the highest quality of care for resident's and families

19. Other duties as assigned