Social Worker, Skilled Nursing

1. Performs each patient’s/resident’s initial comprehensive assessment to determine and best meet the goals of this patient/resident.
2. Works in collaboration with other professional disciplines to develop a patient/resident directed plan of care.
3. Develop discharge plans as determined by patient/resident and their Responsible Party.
4. Refers patients/residents, as necessary, to community resources and other organizations to best meet these discharge plans.
5. Will complete Social Service section of the MDS (Minimum Data Set Assessment) within the CMS mandated time frame
6. Will assist patient/resident with Advanced Care planning.
7. Involves patients and families in the interdisciplinary care process by coordinating and participating in care/discharge planning and initiating referrals for appropriate home care services if necessary prior to the resident’s return to the community.
8. Will facilitate communication with post-discharge residents to insure a successful discharge transition to community.
9. Must ensure that social service progress notes are informative and descriptive of the services provided and are completed in a timely manner as directed by Department of Public Health and CMS regulations.
10. Will participate in and attend various committees of the facility as required.
11. Will assist in educating residents and staff in Resident’s rights as mandated by Executive Office of Health & Human Services.
12. Will advocate on behalf of all patients/residents, as needed.
13. Will communicate weekly with Ombudsman Representative of Elder Services, as needed.
14. Must maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information; and adhere to Resident’s rights.
15. Performs other work related duties as requested.

· Bachelor's degree in social work or a related field from an accredited college or university. · Must be licensed in Massachusetts. · Must have, as a minimum, one (1) year supervised social work experience in a health care setting working directly with the elderly or disabled. · A member in good standing in the National Association of Social Workers and Academy of Certified Social Workers, Inc., preferred. · Must be able to read, write, speak, and understand the English language. · Knowledge of community resources. · Must possess the ability to make independent decisions when circumstances warrant such action. · Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. · Must be a supportive team member, contribute to and be an example of team work and team concept. · Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public. · Must have patience, tact, cheerful disposition and enthusiasm, as well as be willing to handle residents based on whatever maturity level in which they are currently functioning. · Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing social services.