Come Join our Team!

Full Time

The primary purpose of this position is to plan, organize, develop, and direct the overall operation of our nursing facility in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis.

Job duties include but are not limited to:

• Assist in the planning, developing, organizing, implementing, evaluating and directing of the social service programs of this facility.
• Meet with administration, medical and nursing staff, and other related 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.
• Assist in the developing, administering, and coordinating of social services policies and procedures.
• Keep abreast of current federal and state regulations, as well as professional standards, and make recommendations on changes in policies and procedures. (Reference attached pages Sections i-ii).
• Assist in developing and implementing policies and procedures for identifying the medically related social and emotional needs of the patient/resident.
• Participate in community planning related to the interests of the facility and the services and needs of the patient/resident and family.
• In absence of Admission Coordinator receive and coordinate all referrals for admissions as necessary and not limited to:
• Conducting telephone, on-site, and off-site interviews, tours, and meetings;
• Coordinate all referrals through the admission process;
• Work cooperatively and establish effective communication with all departments during the admission process;
• Complete all required pre-admission and admission process documentation for all residents.
• Coordinate discharge planning, development and implementation of social care plans and patient/resident assessments.
• Interview patients/residents/families as necessary and in a private setting.
• Involve the patient/residents/family in planning social service programs when possible.
• Assist in arranging transportation to other facilities or outpatient services when necessary.
• Refer patient/resident/families to appropriate social service agencies when the facility does not provide the services or needs of the patient/resident.
• Complete PASSRR screen evaluations;
• Coordinate ICF/Skilled levels of care for all admissions, transfers, or upon change of payer status
• Inform the patient/resident/family of the patient’s/resident’s personal and property rights
• Ensure the resident and family are aware of provided information with Long term care’s Residents Bill of Rights, Advanced Directives, Do Not Resuscitate provisions;
• Ensure residents unable to serve as their own responsible person are afforded legal and authorized advocacy for health and financial services;
• Provide consultation to members of our staff, community agencies, etc., in efforts to solve the needs and problems of the patient/resident through the development of social service programs.
• Maintain an excellent working relationship with the medical profession and other health related facilities and organizations.
• Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment with fellow co-workers.
• Maintain CONFIDENTIALITY of all pertinent patient/resident care information to ensure patient/resident rights are protected.
• Coordinate social service activities with other departments as necessary.
• Perform charting duties as necessary including but not limited to the following:
• Initiate, label, and complete timely initial admission assessments that meet the requirements of state regulations and policies of the facility;
• Initiate, label, and complete a Social Service History which is comprehensive addressing potential and immediate needs, etc;
• Initiate, label and complete timely Initial Assessment Notes which address and are not limited to the following:
  • Affect upon admission;
  • Adjustment, coping needs;
  • Strengths and limitations of the resident;
  • Potential social services needs;
  • Family reaction, participation, support;
  • Discharge plan/potential;
  • Reflective of responsibility state clearly resident’s capability for own decision. Address status of Do not resuscitate, power of attorney for finances and/or health care, or presence of adjudicated guardianship status;
  • Identify all medications used for mood, emotion, mental diagnosis, and behaviors and notes reflect appropriateness and review by the Interdisciplinary Care Team;
  • Spiritual needs.
• Quarterly initiate, label, and complete timely Social Service Progress Notes which address and not limited to the following. Coordinate and ensure compliance with the designated MDS assessment referral date:
  • Identify changes and needs since last assessment;
  • Address all psychosocial needs;
  • Address all behaviors, moods, emotions, and mental diagnosis. Notes need to reflect all chemical, physical, and psycho-pharmaceuticals used to control moods, behaviors, and/or symptoms of mental disorders;
  • Identify reasons for resident’s distress and interventions efficacy;
  • Family involvement and/or responsible or concerned persons;
  • Current social service needs;
  • Continued status/appropriateness of discharge plan/potential;
  • Continued status/appropriateness of advanced directives, DNR. Note any changes in resident or legal status