Social Services Assistant

Purpose of Your Job Position

The Social Service Assistant will work with residents in the nursing home by identifying 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 National Association of Social Workers (NASW) Code of Ethics along with strict adherence to government regulations. The nursing home social worker is responsible for fostering a climate, policies and routines that enable residents to maximize their individuality, independence and dignity in accordance with the Federal Regulations, the requirements of this State, and policies and goals of the facility. This climate shall provide residents with the highest practical level of physical, mental and psychosocial well-being and quality of life.

Delegation of Authority

As Social Service Assistant you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Function

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is an essential function of the position.

Primary Duties and Responsibilities

In fulfilling the primary duties and responsibilities, the nursing home Social Service Assistant shall exercise professional judgment in carrying out a variety of activities that maximize the well-being and quality of life of residents. The following is a listing of those duties in accordance with current professional Social Work practice standards.

Administrative

1. Review facility policies and procedures as part of the facility's interdisciplinary team to assure compliance with state and federal regulations. Keep informed of current federal and state regulations, as well as professional standards, and make recommendations on changes in policies and procedures to the Social Services Director ("Director") or Administrator.

2. Develop, maintain and utilize a listing of current community resources that are useful to residents and their families / significant others / responsible parties.

3. Must adhere to all HIPAA requirements.

4. Understand and meet all government requirements for Social Service documentation.

5. Document progress in meeting the psychosocial needs of residents.

6. Maintain a quality working relationship with the medical profession and other health related facilities and organizations.

7. Assist in implementing appropriate plans of action to correct identified deficiencies.

8. Participate in facility surveys (inspections) made by authorized government agencies, as necessary or as may be directed.

9. Meet with administration, medical and nursing staff, as well as other related departments in planning Social Services interventions.

10. In the absence of the Director, assume the authority, responsibility, and accountability of directing the Social Service Department.

Advocacy / Resident Rights

1. Work with the interdisciplinary team and administration to promote and protect resident rights and the psychological well-being of each resident. Prevent and address resident abuse as mandated by law and professional licensure.

2. Identify community changes and opportunities such as legislation, regulations and programs that affect nursing home residents.

3. Provide information to residents / families / responsible party as to Medicare and Medicaid, and other financial assistance programs available to the resident.

4. Ensure that all residents upon admission have an accurate Preadmission Screening and Resident Review (PASRR) and that the record is updated and maintained as needed with change in resident condition.

5. Communicate and coordinate assistance with Medicaid applications as needed.

6. Ensure that all new residents / family / responsible party on admission have been given resident rights.

7. Issue and ensure proper notice is given and procedure is followed including time frames, for Notices of Medicare Non Coverage, Skilled Nursing Facility Advanced Beneficiary Notice and Transfer and Discharge Notices.

8. Review complaints and grievances made by the resident and make a written or oral report to the Director and Administrator indicating what action(s) were taken to resolve the complaint or grievance. Follow facility's established procedures.

9. Review with the resident / responsible party the resident's advanced directives / code status on admission, quarterly, and with changes in condition.

10. Educate the resident and responsible party regarding rights related to advanced directives. Assist the resident / responsible party and coordinate with nursing and the Attending Physician the resident / responsible party regarding the resident's wishes and expectation for advanced directives / code status.

11. Assist the resident in completing Health Care Proxies, Durable Power of Attorney, and Living Wills.

12. Utilize the state designated orders for life sustaining treatment, i.e. DMOST, POLST, MOLST, and facility forms as directed by the Administrator and Medical Director.

13. Educate the resident / responsible party and the interdisciplinary care team on resident's bed hold rights in accordance with the regulations specific to Federal and State guidelines.

14. Coordinate resident room changes including documentation in the resident's medical record that the resident and responsible party if applicable were notified of the room change and accepting of the room change, the reason for the room change and documentation that the resident's roommate was also notified of receiving a new roommate.

15. Assess and provide support for adjustment to a new room and / or new roommate.

Clinical Assessment and Care Planning

1. Complete a social history, complete relevant sections of the Resident Assessment Instrument, MDS, and CAA Summary, and Social Services evaluations for all residents.

2. Communicate any significant changes in a resident's condition based on MDS assessments, observation, documentation, and critical thinking.

3. Complete psychosocial assessment for each resident that identifies social, emotional, and psychological needs.

4. 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 interventions.

5. Ensure that all Social Services personnel are aware of the Care Plan and that Care Plans are used in providing daily Social Services to the resident.

6. Ensure that all charted progress notes are informative and descriptive of the services provided and of the resident's response to the service.

7. Review nurses' notes to determine if the Care Plan is being followed. Report problem areas to the Director of Nursing Services.

8. Coordinate with the resident / responsible party and interdisciplinary team regarding referrals for Hospice / Palliative Care.

9. Review the clinical dashboard daily for due and outstanding User Defined Assessments (UDAs), Care Plan reviews, draft notes, and high-risk progress notes.

Clinical

Therapeutic and Behavioral Interventions

1. 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, psychological needs and are Care Planned appropriately.

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

3. Provide support groups for residents / family members / significant others / responsible party as appropriate to their needs,

i.e. dementia, substance abuse, grief and loss, etc.

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

5. Coordinate referrals for mental health services for the residents while in the nursing home in accordance with the mental health resources available at the facility, i.e. in house psychiatry, psychology, clinical social work, outpatient psychiatry, telemedicine services.

6. Review mental health consults for recommendations related to behavioral interventions and update the resident's Care Plan appropriately.

7. Update the resident's Care Plan for changes in psychotropic medications per MD orders.

8. Communicate appropriately and timely with the responsible clinician and follow the facility protocol for monitoring self-harm in response to residents with suicidal ideation, for example thoughts that the resident would be better off dead or hurting themselves in some way.

9. Communicate appropriately and timely with the responsible clinician and follow the facility protocol for monitoring homicidal ideation.

Clinical

Discharge Planning

1. Maintain written and verbal communication on resident discharges to the community with the Interdisciplinary Team.

2. Coordinate the resident discharge planning process and make referrals for appropriate home care services prior to the resident's return to the community, i.e. Home Health Care Agency, Area on Aging, community Social Services Agencies, etc.

3. Complete and audit the status of Section Q referrals and referrals to the Local Contact Agency.

4. Make referrals for durable medical equipment for the resident's needs in the community, i.e. hospital bed, oxygen, wheel chair, shower chair, rolling walker, etc.

5. Coordinate referrals for outpatient services including outpatient rehabilitation, mental health follow up, primary care physician appointments and other consults that are assessed as needed by the Attending Physician and Interdisciplinary Team, i.e. cardiology, pulmonology, dialysis, wound care, etc.

6. Ensure that Transition of Care Booklets are completed timely, and are provided to the resident / family / responsible party / healthcare coach as well as PCP and community agencies as indicated and as approved by the resident / responsible party.

7. Provide telephone follow up contact with the discharged resident and / or responsible party within 24-72 hours post discharge.

8. Maintain accurate record of the discharge follow up call.

9. Communicate with the Interdisciplinary Team and the Home Health Care Agency as needed regarding any needs that were discussed by the resident / responsible party during the post discharge follow-up call.

Clinical

Therapeutic Leave of Absence

1. Communicate with the resident, the family / responsible party and interdisciplinary team regarding requests for therapeutic leaves of absence (LOA).

2. Assist in ordering necessary equipment for LOA, i.e. portable oxygen.

3. Coordinate the assessment for caregiver training needs for the LOA.

4. Document in the resident's medical record the purpose of the LOA, the location, the length of time, and method of transportation.

5. Assist in planning for transportation needs for the LOA.

6. Communicate with the Interdisciplinary Team and resident / responsible party regarding allotted days for the therapeutic leave of absence in accordance with state and federal guidelines.

Education

1. Educate the staff regarding the psychosocial needs of the residents and their families / significant others / responsible party regarding the needs of aging and disability.

2. Educate staff regarding cultural diversity and each staff member's importance when caring for residents.

3. Educate staff regarding resident rights and how to recognize and prevent abuse, neglect and maltreatment.

4. Educate residents and families / significant others / responsible party regarding their rights and responsibilities, effective problem solving and the extent of community, health and Social Services that are available to them, including those necessary for effective discharge planning.

5. Supervise students assigned to Social Services in accordance with the respective school guidelines and monitor and document the progress of their work.

Committee Functions

• Serves on, prepares for, participates in, and attends various committees of the facility including Daily clinical meeting, daily case management, resident care conference, weekly utilization review, weekly risk management, and monthly Quality Assurance.
• Participate and schedule Rapid Recovery Meetings.
• Evaluate and implement recommendations from established committees as they may pertain to Social Services.
• Participate in resident or group council meetings, as requested, and provide support services to such council.

Personnel Functions

Staff Development

Safety and Sanitation

Equipment and Supply Functions

Miscellaneous

Working Conditions

Education

Experience

Specific Requirements

Physical and Sensory Requirements

(With or Without a Reasonable Accommodation)