JOB SUMMARY: The Social Worker will offer 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), a long-term care facility in Rochester, NY.
This position will oversee the Case Management and resident advocacy for a 23-bed rehab unit and a 25-bed long-term care unit.
ESSENTIAL JOB FUNCTIONS
• Comply with the Code of Ethics of the National Association of Social Work.
• Ensure the completion of the MDS 3.0 for social work per facility policy.
• Ensure Residents to be provided with the least restricted environment and medication regime to
ensure a quality, resident centered experience at ECH.
• Provide supportive contact to Residents and family members as they acclimate to life at ECH as well
as provide them with the opportunity to express feelings associated with long term care life.
• Follow established departmental standards and procedures for documentation, 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.
• Provide ongoing assessments of Residents functional, emotional and behavioral status,
communicating changes to family/designated responsible party and collaborate with interdisciplinary
team to ensure Residents are provided with quality care.
• Facilitate hospice referral and evaluation for Residents and develop comfort care plan while
collaborating with hospice team to ensure quality end of life care.
• Coordinate 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.
• Coordinate appropriate discharge plans with community agencies to ensure safe discharge.
• Participate in the interdisciplinary Resident care conferences as scheduled and invite Resident and
family members to meetings per policy.
• Provide 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.
• Coordinate room changes in accordance with the resident’s Bill of Rights and departmental
procedure.
• Collaborate with the admissions coordinator to ensure a smooth admission for each Resident and
family members/designated responsible person and discuss ongoing bed availability and room
change issues per protocol.
• Ensure Resident and family members/designated responsible party receive a copy of the Resident’s
Bill of Rights within 48 hours of admission.
• Follow guidelines of HIPPA to ensure confidentiality of each Resident.
• Work as a member of the social work department to assist in the development and implementation of
Person Directed Care.
• Attend facility in-services and staff meetings.
• Attend Resident and family council meetings as needed.
• Provide support to admissions coordinator as needed.
