Social Worker - San Angelo

Mô tả công việc

REPORTS TO:  ADMINISTRATOR RESPONSIBILITIES: To provide medically related social work services so that each resident may attain or maintain the highest practicable level of physical, mental and psychosocial well being.   ESSENTIAL FUNCTIONS:   Advocates daily on behalf of all residents to ensure that their rights are maintained. Reports abuse, neglect or exploitation per State reporting guidelines. Maintains professional working rapport with facility interdisciplinary team and community resources/agencies. Consistently abides by Social Work Code of Ethics and strives to represent Senior Care Centers by exhibiting professionalism and quality work. Completes Social Service History and Social Service Evaluation with newly admitted residents within 14 days. Completes sections “B, C, D, E and Q” of MDS 3.0 on days 5, 14, 30, 60, 90, annually, upon change of condition and upon resident readmission from hospitalization. Educates, reviews and assists residents in completing Advance Directives, Medical Power of Attorney, Out of Hospital Do Not Resuscitate documents. Facilitates referrals to ancillary services including: follow up with the resident and their responsible party, requesting/obtaining physician orders, copying and faxing information to the agency providing the service (Optometry, Audiological, Dental, Podiatry, Counseling, Psychiatry, Psychological testing) on behalf of the residents. Educates/communicates with residents and/or responsible parties about Palliative Care vs. Hospice Care and assists in the referral/transition process of residents to end of life services and end of life decision making. Procures prior authorization numbers for residents with Medicaid who require ambulance transportation to non-emergency medical appointments. Assists with scheduling transportation for residents to medical appointments. Prepares a Social Service Evaluation prior to each resident’s care plan to assess changes/areas of need since their last care plan.  Documents interactions with residents and/or responsible parties that are reflective of assessments performed, assistance provided and issue resolution.  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.,) 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. Prepares care plans including: Advance Directives, DNR, resident personal preferences, behavioral/psychosocial issues. Facilitates resident room changes including: 5-day relocation notice, follow up with resident, responsible party, roommate, physician and nursing and documentation of afore mentioned process. Reviews resident’s psychosocial well being d/t loss of a family member, friend or roommate. Attends Resident Council meetings only if invited by the Council members and assists in resolution of any issues presented. Facilitates proper procedure on initiation/completion of Grievance Reports and assists in maintaining the facility Monthly Grievance Log. Attends and provides quarterly information for Performance Improvement/Quality Assurance meetings including: all resident referrals made in last quarter, all behavioral issues addressed/resolved in last quarter, tracking and trending of grievances within the facility during last quarter. Attends Standards of Care meetings and follows up on any Social Work issues discussed. Performs bi-annual reviews of all resident charts to ensure that assessments, documentation, directives and care planning are current, consistent and appropriately placed in the chart. Maintains knowledge of Federal and State Regulations for long-term care facilities. Uses tactful, appropriate communications in sensitive and emotional situations. Promotes positive public relations with patients, residents, family members and guests.  Use appropriate work place behavior and adhere to dress code at all times.  OTHER DUTIES:   As this job description is not intended to be all-inclusive, the employee will be expected to perform other duties as assigned. Supports the Facility. Is knowledgeable of patient/resident rights and promotes an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment. Supports and participates in common teamwork: Cooperates and works together with all co-workers; plan and complete job duties with minimal supervisory direction, including appropriate judgment. Uses tactful, appropriate communications in sensitive and emotional situations. Reports complaints, problems and concerns regarding co-workers, management or residents in accordance with company policy.                                                 Promotes positive public relations with patients, residents, family members and guests. Completes requirements for in-service training, acceptable attendance, uniform and dress codes including personal hygiene, and other work duties as assigned. Agrees to comply with the Code of Conduct.                                                                                                                                                 WORK CONDITIONS:        As assigned; including some weekends, evenings and holidays.  Non - Exempt Position.     Physical Requirements:     Able to lift 50 pounds for routine performance of essential functions. AA/EEO/M/F/D/V