JOB SUMMARY: As a 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 residents. You will interview, coordinate and refer residents to resources that have been identified and promote activities that will help the resident and, when appropriate, their families to meet their social and emotional needs. You must be familiar with standard concepts, practices and procedures within the field.

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

● Report abuse, neglect or exploitation per state reporting guidelines

● Maintain professional working rapport with facility interdisciplinary team and community resources/agencies

● Consistently abide by Social Work Code of Ethics and strive to represent Caraday Healthcare by exhibiting professionalism and quality work

● Complete Social Service History and Social Service Evaluation with newly admitted residents within 14 days

● Complete sections "B, C, D, E and Q" of MDS 3.0 as scheduled, including OBRA and PPS assessments

● Work through CAA and care plan process for each MDS area triggered

● Coordinate meetings and patient needs in accordance with PASRR guidelines

● Educate, review, and assist residents in completing Advance Directives, Medical Power of Attorney, and Out of Hospital Do Not Resuscitate documents

● Facilitate referrals to ancillary services including following up with the resident and their responsible party, requesting/obtaining physician orders, and copying/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

● Procure 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 review of the care plan as assigned and prior to each resident's care conference to assess changes/areas of need

● Document interactions with residents and/or responsible parties that are reflective of assessments performed, assistance provided and issue resolutions

● Discharge preparations with residents and/or responsible parties throughout stay in facility to culminate all community services requested/required

● Discharge planning on behalf of residents including requesting/obtaining appropriate physician orders, communication and follow up with community resources (Home Health Agency, Equipment Company, Primary Care Physician, Hospice Agency, CBA Agency, Transportation Agency, Meals on Wheels Agency, Support Groups etc.,), and copying pertinent information from resident's chart to forward to agencies that require it in order to bill for services. Preparation and review of Discharge Instructions for Care with the resident and responsible party. Documentation of all discharge planning. Follow up with resident and responsible party post discharge to ensure that resident's transition back into the community was as seamless as possible

● Prepare care plans including Advance Directives, DNR, resident personal preferences, and behavioral/psychosocial issues

● Facilitate resident room changes including five-day relocation notice, follow up with resident, responsible party, roommate, physician and nursing, and documentation of aforementioned processes

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

● Attend Resident Council meetings only if invited by the Council members and assist in resolution of any issues presented

● Facilitate proper procedure on initiation/completion of Grievance Reports and assist in maintaining the facility Monthly Grievance Log

● Attend Performance Improvement/Quality Assurance meetings and provide quarterly information including all resident referrals made in last quarter, all behavioral issues addressed/resolved in last quarter, and tracking and trending of grievances within the facility during last quarter

● Attend Standards of Care meetings and follow up on any Social Work issues discussed

● Perform quarterly reviews of resident charts to ensure that assessments, documentation, directives, and care planning are current, consistent, and appropriate

● Maintain knowledge of federal and state regulations for long-term care facilities

● Develop and maintain a good working rapport with intra-department personnel, other departments within the facility, and outside community health, welfare, and social agencies to ensure that social service programs can be properly maintained to meet the needs of the patients/residents

● Keep up to date with current federal and state regulations as well as professional standards, and make recommendations on changes in policies and procedures to the department director or Administrator

● Understand and adhere to the guidelines of “Residents Rights” and assure resident safety

QUALIFICATIONS:

Required

● Bachelor's Degree in Social Work or a Human Services field including Sociology, Gerontology, Special Education, Rehabilitation Counseling, and Psychology

● Current Social Worker license

● Must be a skilled communicator, director and motivator; able to organize and prioritize many tasks effectively

● Able to react to emergency situations appropriately when required

Preferred

● 2 years of experience in a long term care, hospital or other related medical facility