Licensed Social Worker

Licensed Social Worker – Avir at Plainview

Department: Social Services
Reports To: Administrator / Director of Nursing (as designated by facility)
FLSA Status: Exempt or Non-Exempt, as determined by facility policy
Employment Status: Full-Time
Work Location: Avir at Plainview, Plainview Texas, Formerly Prairie House

Position Summary

The Licensed Social Worker is responsible for providing professional social services to residents and their families to promote the highest practicable level of psychosocial well-being, emotional health, dignity, and quality of life.

The Social Worker serves as an advocate for residents, assisting with adjustment to the nursing facility environment, care planning, discharge planning, psychosocial assessments, resident rights, and coordination of community resources. This position works collaboratively with nursing, rehabilitation, dietary, activities, administration, and other interdisciplinary team members to ensure residents receive comprehensive, person-centered care in accordance with applicable federal and state regulations.

Essential Duties and Responsibilities

1. Resident Assessments and Care Planning

• Complete psychosocial assessments and evaluations upon admission and as required by facility policy and regulatory guidelines.

• Identify residents' psychosocial, emotional, behavioral, social, and discharge-planning needs.

• Participate in interdisciplinary care plan meetings and provide recommendations regarding individualized resident care.

• Develop, implement, and update social service care plans based on residents' identified needs, preferences, and goals.

• Monitor residents' adjustment to the facility and intervene when psychosocial concerns arise.

2. Resident and Family Support

• Provide emotional support, counseling, crisis intervention, and advocacy to residents and their families.

• Assist residents and families with adjustment to long-term care placement, changes in health status, and end-of-life concerns.

• Facilitate family meetings and communicate concerns or changes in resident needs to the appropriate interdisciplinary team members.

• Promote resident dignity, independence, self-determination, confidentiality, and quality of life.

• Assist residents and families with grievances, concerns, and requests for assistance.

3. Admission, Discharge, and Transition Planning

• Assist with the admission process, including psychosocial interviews and identification of resident needs.

• Coordinate discharge planning with residents, families, physicians, and interdisciplinary team members.

• Assist residents and families in identifying appropriate community resources, home health services, transportation, financial assistance, and other support services.

• Ensure discharge plans address residents' individual needs and support a safe and appropriate transition.

• Document discharge planning activities and follow-up recommendations.

4. Resident Rights and Advocacy

• Protect and promote residents' rights in accordance with federal and state regulations.

• Advocate for residents' preferences, choices, privacy, dignity, and freedom from abuse, neglect, and exploitation.

• Assist residents with understanding their rights, grievance procedures, and available resources.

• Participate in investigations and follow-up regarding resident concerns and grievances as assigned.

• Report suspected abuse, neglect, exploitation, or mistreatment immediately in accordance with facility policy and applicable reporting requirements.

5. Psychosocial Services and Crisis Intervention

• Identify and address psychosocial concerns, including depression, anxiety, grief, isolation, behavioral changes, and adjustment difficulties.

• Provide appropriate interventions and referrals for additional counseling or mental health services when indicated.

• Collaborate with nursing and medical professionals regarding residents experiencing emotional or behavioral distress.

• Assist with crisis situations, significant life changes, and family conflicts affecting resident well-being.

6. Regulatory Compliance and Documentation

• Maintain accurate, timely, and confidential social services documentation in the resident medical record.

• Complete required assessments, progress notes, care plans, referrals, and discharge documentation.

• Ensure documentation supports compliance with applicable CMS regulations, state licensing requirements, and facility policies.

• Participate in facility surveys, audits, quality assurance activities, and performance improvement initiatives.

• Maintain confidentiality and comply with HIPAA and all applicable privacy requirements.

7. Interdisciplinary Collaboration

• Participate in daily clinical meetings, care conferences, and interdisciplinary team discussions.

• Communicate relevant resident concerns and psychosocial changes to appropriate departments.

• Work collaboratively with nursing, rehabilitation, dietary, activities, medical providers, and facility leadership.

• Assist in developing strategies to improve resident satisfaction, psychosocial well-being, and overall quality of care.

8. Additional Responsibilities

• Assist with facility-wide initiatives designed to improve resident quality of life and satisfaction.

• Maintain professional relationships with community agencies and referral sources.

• Participate in required staff education and professional development.

• Perform other duties as assigned by the Administrator or designee within the scope of professional licensure.

Minimum Qualifications

• Bachelor's degree in Social Work (BSW) from an accredited college or university, at minimum, or other degree/education as permitted by applicable state and federal regulations.

• Current, valid Social Work license or credential required by the state in which the facility operates.

• Knowledge of long-term care operations, resident rights, psychosocial assessments, discharge planning, and interdisciplinary care planning.

• Knowledge of applicable CMS regulations, state nursing facility requirements, HIPAA, and mandatory reporting obligations.

• Strong verbal and written communication, organizational, problem-solving, and interpersonal skills.

• Ability to work effectively with older adults, individuals with disabilities, families, and interdisciplinary healthcare professionals.

Preferred Qualifications

• Previous experience working in a skilled nursing facility, nursing home, rehabilitation center, or long-term care setting.

• Experience with MDS processes, care planning, discharge planning, and psychosocial documentation.

• Familiarity with PointClickCare or other electronic medical record systems.

• Experience with dementia care, behavioral health, crisis intervention, and family counseling.

Knowledge, Skills, and Abilities

The successful candidate must demonstrate:

• Compassion, patience, empathy, and professionalism.

• Strong advocacy and resident-centered care skills.

• Ability to manage multiple responsibilities and meet regulatory deadlines.

• Ability to maintain appropriate professional boundaries.

• Excellent communication and conflict-resolution skills.

• Ability to exercise sound professional judgment and maintain confidentiality.

• Ability to work independently and as part of an interdisciplinary team.

Physical and Environmental Requirements

• Ability to work in a healthcare environment with frequent interaction with residents, families, and staff.

• Ability to sit, stand, walk, and move throughout the facility during the workday.

• Ability to perform essential job functions with or without reasonable accommodation.

• Must comply with infection prevention, safety, and facility emergency procedures.

Performance Expectations

The Licensed Social Worker is expected to:

• Maintain timely and accurate documentation.

• Complete required assessments and care plans within applicable regulatory timeframes.

• Demonstrate consistent resident and family advocacy.

• Support resident satisfaction and psychosocial well-being.

• Maintain compliance with federal, state, and facility requirements.

• Demonstrate professionalism, accountability, and effective interdisciplinary communication.