Social Worker, BSW, MSW

Job Summary:

     The facility’s Social Worker plays a vital role in supporting each resident’s emotional, social, and psychological well-being. This position ensures that residents and their families receive appropriate support, advocacy, and resources to navigate transitions, care planning, and quality-of-life concerns. The Social Worker collaborates with interdisciplinary teams to promote holistic, person-centered care in compliance with federal and state regulations. This person provides for medically related social services to attain or maintain the highest practicable physical, mental or psychosocial well-being of each resident residing in this facility home.  These services are offered to assist the resident and the resident’s family member(s) in maintenance and improvement of each resident’s ability to control everyday physical needs, mental needs, and psychosocial needs.

Job Classification:

Department Director

Supervision:

Supervised by Administrator of the Facility

Key Responsibilities

• Resident Support & Advocacy
  • Conduct psychosocial assessments upon admission and as needed
  • Develop individualized care plans addressing emotional, social, and behavioral needs
  • Provide counseling and crisis intervention for residents and families
  • Advocate for residents’ rights and dignity in all aspects of care
• Care Coordination
  • Participate in interdisciplinary team meetings and care plan conferences
  • Facilitate discharge planning, including coordination with external agencies
  • Assist with transitions between levels of care (e.g., hospital, hospice, home)
• Compliance & Documentation
  • Maintain accurate and timely documentation in accordance with F-tag regulations
  • Ensure compliance with CMS, state, and facility policies regarding social services
  • Monitor and report changes in residents’ psychosocial status
• Family & Community Engagement
  • Serve as a liaison between residents, families, and facility staff
  • Educate families on available resources, including financial, legal, and emotional support
  • Coordinate community outreach and volunteer programs
• Behavioral Health & Wellness
  • Support trauma-informed care practices and behavioral health initiatives
  • Collaborate with mental health professionals for assessments and interventions
  • Promote resident engagement through therapeutic activities and social programs

• Neighborhood/Household SSD/AD’s
  • Oversee and Supervise the SSD/AD’s

Personal Skills and Traits Desired:

• Strong verbal and written communication skills
• Evidence of effective problem-solving resolution skills
• Ability to maintain composure in stressful situations
• Resourcefulness
• Possess a concern for the holistic care of each resident
• Willingness to consider advice and opinions of others
• Ability to make decisions and accept responsibility for the consequences
• Leadership and organizational abilities for planning resident care
• Awareness of services and programs available to implement quality care for residents and family members
• Understanding of social and emotional needs of residents and the aging process
• Ability to assess residents’ level of functioning in a social environment
• Patience, tact and positive attitude for dealing with residents at the resident’s level of function
• Willingness to cooperate with staff, family, other agencies, and significant others in the planning of care of each resident
• Empathy, cultural sensitivity and ethical decision-making
• Ability to manage complex situations with professionalism and discretion
• Proficiency in electronic medical records (EMR) and documentation systems
• Ability to coordinate and conduct meetings
• Ability to set and achieve goals
• Ability to be organized and efficient
• Ability to meet deadlines
• Ability to train and motivate others
• Ability and willingness to act as a role model in conduct and appearance
• Basic computer skills
• Knowledge, experience, and understanding of dementia and best practices for dementia care
• Experience with end-of-life support
• Experience, knowledge and understanding of behavioral health
• Knowledge of health equity principles and trauma-informed care
• Knowledge and understanding of person-centered, person-directed care
• Have a working knowledge of the skills necessary to provide continuity in coordination of resident care including but not exclusive to:
  • Skills to interview residents, family members
  • Ability to communicate with community resources, etc.

Physical Requirements:

The employee must be able:

• To move intermittently throughout the workday
• See, hear or use prosthetic devices to enable use of the senses adequately
• Assist with the evacuation of residents
• Sitting, bending, stooping for extended periods of time
• Dexterity of hands and fingers to operate equipment
• Ability to lift, move, push or pull a minimum of fifty (50) pounds

Work Environment:

• Works in well-lighted, well-ventilated areas as well as throughout the nursing service areas
• Subject to frequent interruptions
• Involved with residents, family members, personnel, visitors, etc., under all conditions and circumstances
• Communicates with nursing personnel, and other departmental supervisors
• Willingness to work beyond normal working hours and in other positions temporarily, when necessary
• The primary work environment is throughout the facility and at times the work is stressful. 
• May be exposed to blood, body fluids, infectious diseases and air contaminants
• May be subject to work call-back during times of facility emergency or disaster preparedness functions
• Attend and participate in continuing educational programs as directed
• Be economical and careful with supplies, equipment, etc.
• Follow all established policies and procedures to include nursing care procedures, safety regulations, personnel policies, etc., to assure that quality resident care can be maintained

Confidentiality of Information

• The employee in this position may not disclose any record (via any media format, known or unknown
• May not disclose any resident or facility information, any system log-in codes or password assigned or permit any unauthorized access to resident/resident or facility information without express written consent of the facility management

Fair Labor Standards Act

• This facility’s compensation for this position exceeds the mandates of the Fair Labor Standards Act and as such this position is exempt from overtime coverage

Position Acknowledgement

By accepting this position, the employee agrees to perform the tasks outlined in this job description, as well as other tasks that may become necessary to the position.  Failure to perform the duties in a safe and professional manner and in accordance with the facility established policies and procedures may result in disciplinary action including termination of employment.  The employee will receive a copy of this job description and a signed copy will be placed in the employee’s personnel employment file. 

Assigned Tasks (with or without reasonable accommodation)

• Documents pertinent psychosocial information related to residents including at least quarterly progress notes and as needed documentation in electronic clinical record
• Assesses and plans for psychosocial needs of each resident
• Attends care conferences and implements the social services component including cognitive, communication, mood and behavior of the resident’s care plan and assist the resident to meet planned goals
• Monitors the residents’ progress in improvement of physical, mental and psychosocial functioning
• Acts as liaison to family, community, and social service agencies
• Provides referrals for counseling services to residents and family members
• Assists other team members and resident in development of alternative therapeutic strategies for residents on psychotropic medications
• Coordinates with families to complete facility admission paperwork
• Coordinates with AAA for PASAAR and CARE Assessments
• Coordinates admission and discharge process with facility, staff and individuals outside facility
• Coordinates appointments for residents for referrals of sensory deficits including but exclusive to eye care, hearing care, dental care, psychiatric care, etc.
• Provides financial and legal assistance through referrals to appropriate resources
• Participates in homes’ in-service programs
• Familiarize family and resident with life routines of home at the time of admission
• Assist residents to meet miscellaneous needs as identified including clothing, appliances, appointments, etc.
• Assists residents to participate in individual and group programs and to utilize such to the resident’s best advantage
• Develops, implements, and provides follow-up on social service aspects of the care plan such as specific modifications relevant to treatment for positive responses
• Provides information to resident and family members regarding available services of State Ombudsman program
• Provides assistance to family during resident’s initial separation period by maintaining family contact about resident problems and is able to promote maintenance of resident’s family relationships
• Coordinates the Volunteer program and Junior Volunteer Program
• Consults with staff from community organizations to arrange referrals outside the home
• Assists with coordination of a Resident Council and renders assistance to the Councils at the direction of and with the approval of the Councils
  • Ensures that all concerns voiced during Council meetings are appropriately addressed and followed up on by the appropriate department representative
• Participate with Chief Financial Officer (CFO) in developing a budget
• Fosters family and community support of the program through newsletters, networking, programs that bring family members or members of the community into the home, etc.
• Evaluates the effectiveness of the departments’ operating procedures and modifies procedures accordingly
• Contribute to facility efforts to maintain and/or improve quality of care through participation in following:
  • Attend care plan meetings
  • Serve as a member of Quality Assurance Performance Improvement Committee and Performance Improvement Plan meetings
    • Continuously evaluates the effectiveness of department operating procedures and recommends changes as required
  • Attend meetings as requested by Director of Nursing, Administrator
  • Serve as member of Weekly Medicare & Risk Committee
  • Attend all mandatory in-services including annual dementia training

• Other duties as assigned

EDUCATION:   Bachelor’s or Master’s degree in Social Work (BSW/MSW) from an accredited institution

• State licensure or certification as required (e.g., LSW, LMSW, LCSW) LICENSE: Certification or licensure as appropriate for each person noted above

EXPERIENCE:   1-2 years of experience in a social or recreational program approved by State within the last five (5) years, one of which was full time in a resident activity program in a long-term care, geriatric or healthcare setting preferred

• Familiarity with regulatory standards including CMS, HIPAA, and resident rights