Social Worker at Gilmer

Focused Post Acute Care Partners•Gilmer, TX

1d•Onsite

About The Position

Focused Post Acute Care Partners (FPACP) is seeking a Social Worker to join their team in Gilmer, TX. As a licensed Social Worker, you will act as a primary referral source, interviewing, coordinating, and referring members to community resources to meet their social and emotional needs, and when appropriate, their families. You will need to be familiar with standard concepts, practices, and procedures within the field.

Requirements

Bachelor's Degree in Social Work or a Human Services field including, Sociology, Gerontology, Special Education, Rehabilitation Counseling, and Psychology.
Must be a licensed Social Worker in the state of Texas or obtain within 6 months of hire.
Able to react to emergency situations appropriately when required.

Nice To Haves

Two (2) years of experience in long-term care, hospital, or other related medical facilities.

Responsibilities

Meet with administration, medical and nursing staff, and other related departments in planning social services.
Advocate 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.
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.
Educate, review and assist 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.
Educate/ communicate with residents and/or responsible parties about Palliative Care vs. Hospice Care and assist 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.
Assist with scheduling transportation for residents to medical appointments.
Prepare a Social Service Evaluation prior to each resident's care plan to assess changes / areas of need since their last care plan.
Document 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.
Prepares care plans including: Advance Directives, DNR, resident personal preferences, behavioral/psychosocial issues.
Facilitates resident room changes including five-day relocation notice, follow-up with resident, responsible party, roommate, physician, and nursing and documentation of aforementioned process.
Reviews resident's psychosocial wellbeing due to 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.
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.
Develop and maintain a good working rapport with intra-department personnel, other departments within the facility and outside community health, welfare and social agencies to ensure that social service programs can be properly maintained to meet the needs of the patients / residents.
Keep up to date with current federal and state regulations as well as professional standards, and make recommendations on changes in policies and procedures to the department director or Administrator.