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.
Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects JML’s commitment to CARES: compassion, accountability, respect, excellence and service.
