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Social Worker

Job Number: 


Perform the necessary duties related to a diverse, consistently changing caseload.  Assist with each resident's initial adjustment to their need for a nursing home placement, their orientation to the facility and the services available.  Respond to ongoing concerns/needs involving family/significant others and other staff members, as appropriate.  Initiate the discharge planning process, when appropriate, providing current referrals and resources and implementing the final plan decided upon.  Responsible for meeting all required Federal and State requirements relative to Social Services.


ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned


Initiate and maintain required documentation for the resident's admission file and medical chart.

Review all admission information, designated policies, and Resident Rights and Responsibility with new resident.

Obtain needed signatures/dates received prior to or on the day of admission.

File all admission paperwork on a timely basis.

Complete necessary Social Services paperwork for each resident and file in the medical chart within the required time period.

Complete social history within 10 working days.

Document ongoing significant contacts/conferences with the resident and their family/significant other.

Document room changes and notifications, resident, roommate, and authorized persons.

Complete MDS and care plans within 14 days of admission and update/revise as needed.

Update resident's progress/changes each quarter and on an ongoing basis as needed.

Develop and finalize discharge plans (as/if they arise).






Educate and review regarding advanced directive possibilities and the facility “no CPR policy/bracelet".

Inform resident/family of available related resources on admission and review at monthly update as needed.

Assist the resident/family to implement any desired documents.

Coordinate the resident's advanced directive information, authorization to notify listing and the ID sheet so appropriate people are contacted as needed.

Audit medical charts regarding any changes made while filing other documentation.


Share information with other involved disciplines through case/family conferences and multi-disciplinary team meetings and document accordingly.

Develop and regularly review each resident's plan of care, goals and approaches, level of care, and discharge plans, as designated by specific State or Federal regulations.

Review and update information and documentation to meet resident's condition/needs, including ongoing care plans, conferences, documentation, progress notes and MDS updates.



Remain current on the resident rights and responsibilities per State and Federal regulations; update residents and employees as changes occur.

Review and discuss resident rights and responsibilities per federal/State guidelines with staff and residents, including any changes that may occur.

Participate in annual in-service for all employees.

Meet with each new resident to review Resident Rights and Responsibilities and to discuss any related questions and/or concerns.

Present these rights and responsibilities to current residents through Resident Council meetings.

Review any new rights or changes with each resident and obtain their signature.

Educate and review the facility complaint and missing items process and provide the appropriate forms.


Work with the Creative Resource department to organize and regularly assist with the Resident Council meetings.

Record minutes of the meeting and send copies, as directed.

Keep an ongoing file of all resident council minutes.


Provide appropriate referrals and resources to residents and/or their families regarding issues related to resident needs and/or desires.

Assist with Transit Plus application, obtaining the necessary picture ID and understanding usage.

Be knowledgeable about Medicaid and Medicare programs, eligibility and application requirements.

Assist with completion of necessary forms, obtain an appointment and understand the process.

Apply for this assistance when a resident and/or family cannot or has not done so in a timely manner.

Share available catalogs, community and in house resources as applicable.


Demonstrate professional assessment and counseling skills to deal with issues such as admission adjustment, crises, death and dying, new diagnosis, behavioral problems, etc.

Utilize individual, family and/or group counseling skills appropriately.


Ability to prioritize tasks and structures workload accordingly on a daily basis.

Attend scheduled meetings promptly or report a necessary absence.

Respond promptly to messages and pages.

Document clearly and concisely regarding resident/family contact to benefit the resident and other involved disciplines.

Provide backup for other social service workers when time constraints allow.


Other duties

Keep current with mail and pertinent daily happenings within the facility.

Attend all required in service programs offered by the facility.

Maintain strict confidentiality regarding a resident's ongoing financial, medical and/or personal information.

Attend meetings as scheduled to provide updates, share information and to discuss any questions/concerns.

Attend seminars to keep current on social service related topics.

Present other educational programs and/or support groups as needed.


Maintain work environment in a safe, organized manner.

Demonstrate an acceptable record of attendance and promptness according to facility policy.

Dress to meet department standards.

Accept and complete assignments as delegated.