Social Work & Discharge Planning Assistant
Company: Fairfax Rehabilitation and Nursing Center
Location: Fairfax
Posted on: March 19, 2023
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Job Description:
Fairfax Rehabilitation and Nursing Center - Fairfax Rehab and
Nursing Center -is seeking a -Social Work & Discharge Planning
Assistant. -The ideal candidate must be devoted and compassionate
about their chosen career and is passionate about patient care. The
Social Work & Discharge Planning Assistant is the patient advocate
and bridges the communication between patient, family, and facility
staff. We are looking for a -Social Work & Discharge Planning
-Assistant -who is dependable, self-motivated, team player, and
flexible. -
POSITION SUMMARY
The Social Work & Discharge Planning Assistant is responsible for
assisting in the operation of the center's Social Work & Discharge
Planning department; ensuring that the social, psychological, and
physical needs of all residents in the center are being met. This
position is responsible for coordinating all aspects of the
patient's safe discharge from the center back to home or a lower
level of care.
ESSENTIAL DUTIES & RESPONSIBILITIES GENERAL RESPONSIBILITIES
Document care plans and services provided in the resident's medical
record in accordance with state and federal regulatory requirements
and company policies. Ensure all entries are accurate, timely, and
descriptive of the services provided.
Complete assigned sections on the Minimal Data Set (MDS) in timely
manner.
Arranges and obtains needed durable medical equipment, clothing,
and personal items for residents.
Partners with the clinical team in training staff on resident's
behaviors and appropriate behavioral interventions.
Coordinates home health, hospice, and supportive services,
including making referrals to and obtaining services from outside
agencies as needed.
Participates in leadership team by actively contributing to
decision making, grievance follow-up, building and company-wide
initiatives and attending leadership meetings such as Stand-Up,
Quality Assurance Performance Improvement (QAPI), and other
meetings as required.
Performs other duties as assigned.
SOCIAL SERVICES
Act as resident advocate by ensuring that services are provided in
the resident's best interest and educating on residents'
rights.
Meet with all new admissions to discuss and document the resident's
psychosocial history and identify the current psychosocial
needs.
Communicate regularly with the resident and resident's family
regarding resident needs.
Ensure comprehensive psychosocial care plans are in place for each
resident and are completed within the required timeframe and
updated quarterly and as needed.
Arrange ancillary services including, but not limited to, dental,
ophthalmology, and audiology services.
DISCHARGE PLANNING
Initiates discharge planning upon admission.
Coordinates with the resident and/or resident's representative(s),
the interdisciplinary team, and physician to determine appropriate
discharge plans for transitioning the patient home or to an optimal
care environment.
Schedules and directs timely and efficient discharge planning
meetings for all new admissions.
Utilizes scheduled administrative meetings, the Recovery Map, care
plan meetings, internal and community resources to facilitate
education and planning that provides the patient and family the
support needed in order to resume life in the community or at a
lower level of care.
Assesses the patient's support systems and home situation to assist
in decision-making regarding the patient's discharge plan and
discharge needs.
Facilitates effective bed management by strategic evaluation and
internal arrangement of center beds in order to maximize the
availability of transition and extended care services.
Adheres to company procedures for initiating internal transfers,
and documents room/roommate change processes including
notifications, transfers, interventions, and outcomes in the
patient's medical record.
Coordinate with center's Business Office to ensure timely issuance
of Notice of Medicare NonCoverage (NOMNC) and Skilled Nursing
Facility Advance Beneficiary Notice (SNFABN).
Provide center case management for managed care residents by
collecting and submitting required resident assessments and
progress updates to insurance companies.
PREREQUISITES
Bachelor's degree in social work, human services, or related field
preferred.
Two (2) years of experience in Social Work or related role
Experience in skilled nursing or healthcare environment
preferred.
As a -Fairfax Rehab and Nursing Social Work & Discharge Planning
Assistant, you will enjoy working in an environment that promotes
professional growth and development that offers competitive wages,
PTO, and insurance plans.
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Keywords: Fairfax Rehabilitation and Nursing Center, Washington DC , Social Work & Discharge Planning Assistant, Healthcare , Fairfax, DC
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