Licensed Social Worker at Oak Manor Inc – Schulenburg, Texas

Job Description

The Licensed Social Worker is responsible for providing psychosocial services to residents in accordance with federal regulations, Texas Health and Human Services (HHSC) requirements, and facility policies. The Social Worker assesses residents’ psychosocial needs, participates in interdisciplinary care planning, assists with discharge planning, and supports residents and families in adjusting to long-term care placement.

The Social Worker serves as a resident advocate and works collaboratively with the interdisciplinary team to ensure residents' psychosocial well-being and quality of life.

• Conduct psychosocial assessments upon admission and periodically thereafter.
• Complete required assessments in accordance with CMS and MDS requirements.
• Identify emotional, social, and behavioral needs of residents

• Participate in the interdisciplinary team (IDT).
• Develop and update psychosocial sections of the resident care plan.
• Ensure care plans reflect the resident’s psychosocial status, preferences, and goals.

• Coordinate safe and appropriate discharge planning.
• Assist residents and families with transition planning and community resource referrals.
• Communicate discharge plans with physicians, nursing staff, and family members.

• Provide counseling and emotional support to residents and families.
• Assist families with adjustment to long-term care placement.
• Address resident grievances and concerns.

• Promote and protect resident rights.
• Ensure compliance with federal and state regulations regarding resident rights.
• Assist with grievance resolution and documentation.

• Monitor residents for psychosocial changes.
• Collaborate with nursing staff regarding behavioral or emotional concerns.
• Participate in behavioral interventions when appropriate.

• Maintain accurate and timely documentation in the medical record.
• Ensure documentation meets CMS, HHSC, and facility standards.

• Maintain compliance with:
  • CMS long-term care regulations
  • Texas HHSC regulations
  • Facility policies and procedures
• Participate in surveys and provide documentation as requested.

• Assist with room changes and resident transitions.
• Participate in care conferences.
• Assist with advance directives and end-of-life discussions when appropriate.
• Support activities and quality-of-life programs when needed.

Qualifications

• Bachelor’s degree in Social Work required.
  

• Must hold a current Texas Licensed Baccalaureate Social Worker (LBSW) or Licensed Master Social Worker (LMSW) license.
  

Preferred:

• Experience in skilled nursing, long-term care, or healthcare social services.
• Knowledge of MDS, care planning, and discharge planning.
  

• Knowledge of long-term care regulations
• Strong communication and interpersonal skills
• Ability to work effectively within an interdisciplinary team
• Knowledge of community resources and referral processes
• Strong organizational and documentation skills