N.J. Admin. Code § 8:85-2.6

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:85-2.6 - Social services

(a) Social work services shall have as their fundamental purpose the enhancement of a resident's sense of well-being and control over his life to the fullest extent possible. Social work interventions shall be geared to the resident's strengths, regardless of the extent of disability and shall be designed to enhance coping skills. Social work services shall help residents make the fullest use of nursing facility life, and shall assist residents in discharge to community living.

(b) Social workers shall assist residents with the emotional reactions to pain and functional loss, interpersonal conflicts, fear of death, and other issues impacting on the quality of life. Supportive intervention and encouragement shall be provided. The social worker collaborates with other staff to maximize opportunities for choice and individual expression. Social workers shall monitor a resident's concrete and personal needs and shall serve as primary advocates for the resident in the NF.

(c) Social work services shall not include:

1. Clerical or billing activity;

2. Public relations activity that does not relate to social work services; or

3. Medical records monitoring responsibilities.

(d) Social services staffing and qualifications shall be as follows:

1. Social work services shall be provided in accordance with accepted professional practice by persons who meet the qualifications for social worker as defined in the Social Workers' Licensing Act of 1991 N.J.S.A. 45:15BB-1 et seq. and the licensure requirements of N.J.A.C. 8:39-39. In a NF providing care to children, it is recommended that social service staff receive consultation and training in social care for children; and

2. The facility shall provide a minimum of one full-time equivalent social worker for every 120 residents. In a facility with more than 120 residents, one social worker shall coordinate the work of the department.

(e) Social services assessment and care planning shall be as follows:

1. The social worker shall meet with the resident and family prior to or following admission and shall conduct a social assessment. The social assessment shall be completed within 14 days of admission and shall provide the basis for social service input into the MDS. The assessment shall gather sufficient information to provide an accurate understanding of the individual and shall include the following:

i. Current problem areas, factors that led to placement, and reactions to placement by the resident and family;

ii. Lifestyle and living arrangements before placement;

iii. Family composition, place of birth, marital history, number and location of children;

iv. Social history, which includes personality factors, adaptation to change and disability, interest, religious ties, community activities, medical and psychiatric history, substance abuse; and

v. Discharge criteria;

2. As an integral member of the interdisciplinary team, the social worker shall have active input into the completion of the MDS. The social worker shall attend resident care conferences and quarterly reviews;

3. Resident goals shall be developed as an outcome of the MDS and in conjunction with the interdisciplinary care plan. The resident and family shall be included in the development of goals, if possible;

4. Reassessment of the resident's social needs shall be done annually in conjunction with the interdisciplinary team's review of the MDS. Any new social information shall be recorded in the progress notes;

5. Expectations regarding potential discharge shall be discussed fully with all residents and families on admission. The special needs of residents identified as only needing short term placement (Track II) during pre-admission screening shall be discussed with the resident and family on admission. The family's criteria for discharge shall be fully explored and goals for discharge shall be incorporated into the interdisciplinary care plan;

6. Progress towards goals shall be reviewed with the interdisciplinary team quarterly, or when significant changes occur. Residents and families shall be included in the interdisciplinary care plan review, if possible. Goals shall be based on a current review of resident and family needs and the existing problems to be addressed, as reflected in the current MDS;

7. The social worker shall remain familiar enough with each resident to have an understanding of each resident's psycho-social function and to provide assistance as needed;

8. The social worker shall document important or unusual events and other circumstances which require social service intervention;

9. The record shall reflect the resident's current psycho-social functioning and social work interventions;

10. On readmission of a resident after a period of hospitalization, the social worker shall review the resident's functioning and participate in a reassessment if a significant change has occurred. If a new chart is opened on readmission, a copy of the original social assessment shall be included; and

11. The resident's written consent (or that of a responsible person acting on his or her behalf) shall be obtained before social service information is transmitted to an outside agency or individual. The consent form shall be on the resident's chart. All personnel having access to the record shall be trained to appreciate its confidential nature.

(f) Social services consultation shall be as follows:

1. The social worker shall provide consultation services to residents and family members at the time of admission;

2. Consultation shall be given to the resident when the need arises, upon referral, or when the resident requests it. Situations which may require consultation include problems in adjusting to functional limitations and losses and decline in cognitive functioning involving loss of memory, confusion, and disorientation. Social work consultation may also be used to help residents deal with depression, anxiety, and lack of motivation and other problems affecting interpersonal relationships, such as aggressive or self-isolating behavior;

3. The social worker shall provide crisis intervention when medical or personal crises occur, or when there is a death of a family member or other significant person. Consultation shall also be offered when residents require assistance in mourning losses that occur within the NF;

4. Social work intervention shall be provided when residents exhibit behavior problems, resistance to care, roommate conflicts, or other adjustment difficulties;

5. The social worker shall encourage residents to participate in their treatment plans and activities within and outside the facility, and to form satisfying and appropriate friendships with other individuals in the NF; and

6. The social worker shall provide consultation to staff when interpersonal conflicts or behavior problems occur among residents or between residents and staff.

(g) Social work liaison services shall be as follows:

1. The social worker shall make frequent rounds in the NF, in order to maintain contact and to be accessible to residents who may require or be seeking assistance, and to maintain good communication with other staff;

2. Liaison contact with families shall be maintained by the social worker throughout a patient's stay. The frequency of contact shall depend on the resident's and family's needs;

3. The social worker shall be active in interpreting facility policies and procedures to the resident and his family during the initial period following admission. Questions, problems and complaints shall be addressed promptly;

4. The social worker shall act on a physician's order for a social service consultation within two working days;

5. The social worker shall assist in identifying residents who may be in need of psychological or psychiatric intervention;

6. The social worker shall assist staff in understanding the resident's personal situation and background in order to enhance the ability of staff to deal with the resident appropriately;

7. The social worker shall deal with problems concerning family visitation and support; and

8. The social worker shall serve as a resource to assist families with social service needs and to locate other agencies for assistance.

(h) Social work supportive services shall be as follows:

1. The social worker shall ensure that the resident has sufficient clothing and other personal items and that the resident's basic needs are being met;

2. The social worker shall ensure that the resident's rights are protected and that the Personal Needs Allowance (PNA) is properly utilized;

3. The social worker shall assist residents in understanding and exercising their rights, including the right to make health care decisions;

4. The social worker shall assist the resident in obtaining needed entitlements, community, or legal services;

5. The social worker shall facilitate the acquisition of prosthetic and assistive devices if necessary;

6. The social worker shall assist the resident and/or family in applying for Medicaid benefits, when appropriate;

7. The social worker shall work with the Activities and/or Volunteer Services Departments to obtain visitors for residents who have no supportive family or are otherwise isolated, or who have communication difficulties due to a language barrier; and

8. The social worker may develop support and education groups for residents and families, as appropriate. The social worker shall serve as coordinator or co-coordinator in family support groups held in the NF and shall participate actively in meetings of the Resident's Council.

(i) Social services discharge planning shall be as follows:

1. The social worker shall be the primary staff member responsible for coordinating and carrying out discharge planning;

2. Discharge planning is a process that begins on admission and continues throughout the resident's stay until discharge occurs or is no longer feasible. Discharge planning shall be a collaborative effort by the entire interdisciplinary team. The social worker shall work very closely with nursing staff and other therapists until discharge is accomplished;

3. All residents shall have the right to live in the least restrictive setting possible. The social worker shall, in concert with other members of the interdisciplinary team, identify residents who may have discharge potential;

4. The social worker shall consult the HSDP on admission to determine the recommendations of the professional staff designated by the Department concerning discharge and to identify Track II residents;

5. All residents who appear to be appropriate for discharge shall have their needs reviewed. This review shall include physical and social functioning, medical needs in the community, current and potential supports, resources needed for community living, and psychological readiness for discharge;

6. Discharge planning shall be carried out by means of an interdisciplinary care plan that includes goals and time frames. Social work intervention geared towards discharge shall be recorded as interim notes. The discharge plan shall include:

i. The level of functioning which needs to be achieved by the resident prior to discharge;

ii. Housing needs: the availability of prior living arrangements and the type of future housing needed for successful discharge (for example, apartment, family home, rooming or boarding home, residential health care facility, foster home and/or shared housing);

iii. Any informal support systems available to the resident;

iv. Specific financial assistance needed by the beneficiary; and

v. Specific community resources needed for care in the community (for example, meals-on-wheels, day-care and/or home health assistance);

7. The social worker shall link the resident to necessary community resources and shall follow up to verify that services have been implemented;

8. The social worker shall assist in identifying the family's training needs for resident care in order to implement a successful discharge plan;

9. The social worker shall maintain active contact with the resident, his or her family, and significant others to support their involvement with the discharge plan; and

10. The social worker shall be acquainted with formal resources that are available in the community and shall maintain an up-to-date resource file.

(j) In a NF providing care to children, the social services department shall initiate contact with the local school district when a child is admitted. The social worker shall also continue to serve as the coordinator between the local school district and the NF to facilitate the best care for the child.

N.J. Admin. Code § 8:85-2.6

Recodified from N.J.A.C. 10:63-2.6 and amended by R.2005 d.389, effective 1/17/2006.
See: 36 N.J.R. 4700(a), 37 N.J.R. 1185(a), 38 N.J.R. 674(a).
In (i)4, substituted "professional staff designated by the Department" for "Medicaid RSN"; in (i)6iv, substituted "beneficiary" for "recipient".
Amended by R.2011 d.121, effective 4/18/2011.
See: 42 N.J.R. 1793(a), 43 N.J.R. 961(c).
In (d) through (i), substituted a semicolon or "; and" for a period and "MDS" for "SRA" throughout; and in (i)9, inserted "or her".