Social Worker

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Provides services designed to ensure that the medical, social and emotional needs of each resident are provided for. Works together with other staff (psychological, medical, recreation, nursing, physical therapy, occupational therapy, dietary) to identify potential difficulties for the resident, provides crisis intervention and is available to residents and families for counseling, or other psychosocial services, as indicated.

Assist new residents and their family in the initial adjustment phase, as well as in the ongoing transition to institutional living. Arranges admission interviews with residents, and/or family members, to gather psychosocial information necessary to completion of the initial assessment, and:

Review, discuss, and sign the Admission Agreement.

Provide information to the resident, and/or family member, on residents’ rights and responsibilities, abuse reporting, advance directives, and facility policies and procedures regarding:

Grievance reporting and response.

Misappropriation of property.

Therapeutic leave, bed retention, room change, and transfer/discharge.

Initiates and facilitates small group meetings of residents, family and staff directed at a fuller understanding of the institutionalized resident, and fuller joint participation in improving the residents’ emotional and physical well-being.

In conjunction with the interdisciplinary team, completes the resident assessment, including the MDS, and develops an individualized plan of care for each resident. Notifies resident and/or family member of scheduled care plan reviews and encourages their involvement in this process. Monitors the effectiveness of the plan of care, reviews and revises no less than twice annually, or more often, as indicated.

Works with residents and families, where indicated, on planning for discharge back to the community, or to another environment, as dictated by the needs of the individual resident. Assists the resident and/or family in accessing community and government services through which the resident will receive assistance upon discharge.

Provide sensory and cognitive stimulation to residents, individually and in groups where appropriate, together with recreation and other staff, so that their experience in the facility will be in keeping with the needs and preferences of each resident, and to ensure the highest standard of quality of life.

Serves as resident advocate, ensures that each resident’s privacy, dignity, and autonomy are protected.

Interprets residents’ needs and behaviors and extends professional intervention to all levels of staff, suggesting positive approaches, such as alternatives to restraint use and psychotropic drugs.

Provide assistance and support to family members. Organize bereavement counseling for roommates, families and other affected individuals.

Act as liaison to Federal, State and local agencies providing service to the resident community. Provide information and assistance to residents, and/or family members, on accessing Medicare/Medicaid benefits, or other appropriate legal/financial services.

Facilitates needed communication with other disciplines on behalf of the residents, including medical, nursing, dietary, rehabilitation and psychiatric services.

May perform other duties as assigned by the Director of Social Service.