Rehab Social Worker

Episcopal SeniorLife Communities•Rochester, NY

About The Position

We provide high quality services from skilled nursing and restorative care to housing, assisted living and community-based wellness programs. We are committed to meeting each individual’s needs, in a culturally competent manner, supporting family and loved ones through transitions, and fulfilling our pledge… Life. Inspired Every Day. Under the leadership of the Director, Life Enrichment, the Social Worker is responsible for providing case management services and advocacy for residents while working with the interdisciplinary team to ensure quality care by following the policies and protocols of the Episcopal Church Home (ECH). This position may be required to provide direct care or have access to resident property or belongings.

Requirements

Bachelor's degree in social work or MSW preferred. Completion of a undergraduate or graduate degree in a related.
Agreeable to pursue further education in the field of social work or gerontology if necessary.
A minimum of years experience working in direct service with the geriatric population preferred.
Basic computer skills are necessary including but not limited to the ability to work on a laptop or personal computer, the ability to create, open and save electronic documents and emails, and the ability to navigate between multiple computer programs within a Windows OS required.
Ability to effectively communicate and work as a member of a inter-disciplinary health care team.
Ability to interact courteously, compassionately and tactfully with staff, residents, family members, visitors, vendors and the general public.

Responsibilities

Complies with the Code of Ethics of the National Association of Social Work.
Ensures the completion of the MDS 3.0 for social work per facility policy.
Ensures residents are provided with the least restrictive environment and medication regime to ensure a quality, resident centered experience at ECH.
Provides supportive contact to residents and family members as they acclimate to life at ECH; provides them with the opportunity to express feelings associated with long term care life.
Follows established departmental policies, procedures and standards related to including admissions assessments, supplemental admission documentation, routine progress notes, social work assessments, quarterly summaries, discharge notes, post discharge care plans, Mini Mental State Examination (MMSE), advanced directives (MOLST) and care plans within the established time protocols.
Provides ongoing assessments of residents functional, emotional and behavioral status; communicating changes to family/designated responsible party. Collaborates with interdisciplinary team to ensure residents are provided with quality care.
In collaboration with the hospice team and to ensure quality end of life care, facilitates resident hospice referrals/evaluation, and develops comfort care plan.
Coordinates discharge care plan meetings with resident, family, housing (if applicable, per resident transfer protocol), and interdisciplinary care team to ensure a safe and appropriate discharge plan for residents.
Coordinates appropriate discharge plans with community agencies to ensure safe discharge.
Participates in the interdisciplinary resident care conferences as scheduled; invites resident and family members to meetings per policy.
Provides resident and/or designated representative with transfer policy and appeal process when given notice and transfer is involuntary.
Involvement in the Ethics Committee as appropriate.
Coordinates room changes in accordance with the resident’s Bill of Rights and departmental procedures.
In collaboration with the ECH Admissions Coordinator, ensures a smooth admission for each resident and family members/designated responsible person. Discusses ongoing bed availability and room change issues per protocol.
Follows guidelines of HIPAA to ensure confidentiality of each resident.
Assists in the development and implementation of Person Directed Care.
Attends facility in-services and staff meetings.
Attends resident and family council meetings as needed.
Provides support to admissions coordinator as needed.
Other duties as assigned by management.