Social Services & Resident Advocacy Coord

SNF Social Services & Resident Advocacy Coordinator

Serves as the District's formally designated SNF social services representative, responsible for providing and coordinating the medically related social services each resident needs to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The position performs social services assessments; identifies psychosocial needs and barriers; participates in care planning and interdisciplinary team activities; advocates for resident rights; leads social-services aspects of discharge planning and transitions;

coordinates community resources and public-benefit support; assists with advance directives; and promptly escalates resident-safety, abuse, neglect, and rights concerns.

The position works collaboratively with nursing, medical staff, rehabilitation, dietary, activities, administration, residents, families, representatives, community agencies, and the Long-Term Care Ombudsman. It requires sound judgment, discretion, compassion, and strong documentation and communication skills.

Because federal and California requirements apply to a 33-bed SNF regardless of its size, the following controls are part of this position:

• The Incumbent Is the SNF's Designated Social Services Representative, as confirmed in writing by the Administrator and the Director of Nursing. The District Maintains One Current, Unambiguous Job Description for the Position
• Required Social Services Duties Take Priority. Other Assignments, Including any Billing, Administrative, or Clerical Work, May Not Displace or Delay Required Social Services When Doing so Could Affect a Resident's Psychosocial Needs, Well-Being, or Access to Services
• The Administrator and Director of Nursing Establish and Document the Protected Time for Social Services, Based on Census and Resident Needs, and Review it at Least Quarterly
• A Written Coverage Plan Names a Qualified Backup for Absences, Including Care-Plan and Interdisciplinary Meetings
• The Director of Nursing Monitors Completion of Required Social Services Duties and Documentation at Least Monthly and Reports Gaps to The Administrator

Social Services Assessment and Documentation

• Completes the Required Social Services Interview and written Assessment for Each New Resident within the Time frames Required by Federal and California Requirements and SIHD Policy, and Contributes to the Comprehensive Assessment
• Identifies Each Resident's Psychosocial Needs, Strengths, Preferences, Concerns, Barriers, Support Systems, and Discharge Goals, Including Social, Financial, Family, Environmental, and Community Factors
• Completes Required Interview Components of The Assessment (Such as Mood, Cognition, and Discharge-Planning Sections) When Trained and Assigned
• Updates Assessments Quarterly, After Significant Changes, and as Needs Arise, and Documents Interventions and Follow-Up in the Resident's Medical Record
• Writes Timely, Accurate, Signed Progress Notes at the Frequency Required by Applicable California Regulations and SIHD Policy

Care Planning and Interdisciplinary Coordination

• Participates in Resident Care-Plan Meetings and Interdisciplinary Team Activities and Provides Social Services Information and Recommendations
• Develops or Contributes to Resident-Centered Social Services Goals and Interventions with the Resident, Family, Representative, Physician, Director of Nursing, and Care Team
• Coordinates with Nursing, Rehabilitation, Dietary, Activities, Medical Staff, and Administration and Coordinates Coverage for Meetings when Unavailable
• Helps Interpret the Resident's Social, Psychological, and Emotional Needs to the Medical Staff and Care Team

Resident Advocacy and Resident Rights

• Serves as a Resident Advocate and Helps Residents Communicate Concerns, Preferences, and Requests to Appropriate District Personnel
• Informs Residents and Representatives of Resident Rights, Personal and Property Rights, and Available Resources, Consistent with Federal and California Requirements
• Assists Residents and Representatives with Complaints and Grievances, Documents the Concern and Actions Taken, and Reports to the Director of Nursing and the Grievance Official Under SIHD Policy
• Supports Resident Participation in Care Decisions to the Extent Permitted by the Resident's Condition and Applicable Requirements
• Assists Residents with Long-Term Care Ombudsman Referrals and Communications

Admission, Discharge Planning and…