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• Complete psychosocial assessments upon admission and as required by regulation.
• Participate in the Minimum Data Set (MDS) process, including relevant sections related to mood, behavior, and discharge planning.
• Contribute to the development and ongoing review of person-centered care plans.
• Monitor residents’ psychosocial status and document significant changes.

• Provide emotional support and counseling to residents and families.
• Assist residents in adjusting to placement within the facility.
• Facilitate communication between residents, families, and the interdisciplinary team.
• Coordinate family meetings and care conferences as needed.
• Advocate for resident rights and preferences.

• Coordinate safe and appropriate discharge plans in collaboration with the interdisciplinary team.
• Arrange community resources, home health services, durable medical equipment, and transportation.
• Ensure compliance with CMS discharge planning requirements.
• Provide residents and families with education regarding post-discharge services.

• Educate residents and families on resident rights.
• Assist in the investigation and resolution of grievances.
• Maintain documentation of complaints and follow-up actions.
• Support residents in accessing advocacy services such as the Long-Term Care Ombudsman.

• Identify residents with behavioral health or psychosocial needs.
• Coordinate referrals to mental health providers or community agencies.
• Assist with behavior management strategies and interventions.
• Support residents experiencing grief, loss, or end-of-life transitions.

• Collaborate with nursing, therapy, dietary, activities, and medical staff to ensure holistic care.
• Assist with Medicaid and other financial resource applications when appropriate.
• Coordinate room changes and assist with admission and transfer processes.
• Maintain relationships with community agencies and service providers.

• Maintain accurate, timely, and compliant documentation in the electronic health record (e.g., PointClickCare).
• Ensure all social service documentation meets regulatory and facility standards.
• Participate in Quality Assurance and Performance Improvement (QAPI) initiatives.
• Assist with survey preparedness and provide documentation during regulatory inspections.

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