Social Services - Creative Caregivers

Have you thanked a Social Worker this month? March is National Social Worker month! In honor of all they do, I thought it was appropriate to take a look at some of the many things they do for our patients and residents and to support nursing services in the sub-acute/long-term care settings.

We all know it takes the entire interdisciplinary team to make a healthcare facility work well. When every team member knows and does their job well, you can hear angels singing! Oh wait, that is actually the sound of everyone rejoicing after an exceptional survey!! The social services department affects many F-tags and their actions, documentation and care for the residents makes a lot of difference when it comes to resident satisfaction and positive outcomes.

According to CMS, negative psychosocial outcomes (e.g. changes in mood and/or behavior) may result from a facility’s noncompliance with any regulatory requirement. The Social Services department has the responsibility to document and provide a picture of the services and outcomes of our residents to include:

•Psychosocial outcomes

•LTC - psych services, dental and vision

•PAC - Discharge needs

The documentation should, of course, prove that the residents are comfortable and have not had any preventable declines in their psychosocial wellness. The Behavioral Health Services Code of Federal Regulations (CFR) includes items regarding Behavioral Health Services, Sufficient/Competent staff to Care for Residents with Behavioral Health Needs, Treatment/Services provided or offered for Mental/Psychosocial Concerns, Prevention of Behavioral Difficulties unless Unavoidable, Treatment/Services for Dementia, and Medically Related Social Services are some of the areas that are regulated and will be reviewed for compliance during a survey.

A short list of other duties the social worker takes care of on any given day includes:

• Admission assessment and other admitting requirements

• MDS Interviews, Completion, CAAs and Care Plans

• Behavior and Psychotropic Medication Monitoring

• Discharge Preparations and Planning

• Case Management Activities

• Distributing NOMNCs/ABNs

• Care Conferences

• Management of Personalities and Conflicts between Residents

• Countless Intangibles

Admission Assessment and Other Duties

Soon after admission, the social worker is responsible for completing their Admission Assessment. This assessment serves many purposes. First and foremost, it allows for getting acquainted with the resident, learning their wants and needs, assists with goal setting and sets the stage for discharge planning or for their long-term stay in the nursing center.

Of course, there is a regulatory component attached to the admission process as well. F Tag 620 is related to a uniform Admissions Policy which also addresses resident rights for discharge, transfer and room changes. It also serves as proof that the care planning process and discharge planning did, in fact, begin upon admission. It supports person-centered care and prompts us to ensure the resident's rights are adhered to. F Tag 740 is Behavioral Health Services. It requires understanding what needs the resident has related to their psychological status and is a must upon admission. Known behavioral and psychological conditions should be care planned immediately. F Tag 678 is regarding a resident's code status and advanced directives - this is probably THE most critical piece of information needed upon admission in the event it's needed. The Social Worker is usually the individual who seeks this information out from the resident or family and ensures the correct documentation is on record (POSLT, Advance Directives, MD Orders as necessary).

By the end of the 2nd or 3rd day after admission, the social services department should have a really good idea of the resident's needs, goals and expectations. Much of this information should be conveyed to the IDT in a Morning Meeting, Medicare Meeting, or Daily Huddle.

Interviews, MDS Completion, CAAs and Care Planning

Interviews for the MDS process will usually begin to occur a few days after admission. However, exceptions do occur, for example, if an ARD is set earlier in the stay to capture appropriate payment rates from hospital services. In this case, the interview may occur as early as day 1, 2 or 3. As a team, everyone should be aware of any early ARDs so that interviews are not missed as this could cause a loss of revenue. Interviews not only affect payment, but also capture the resident's voice. All residents should be interviewed unless they cannot answer the questions. Interviews should be completed following the RAI instructions in Appendix D of the RAI Manual. There are also specific instructions regarding each interview in RAI Manual. Social Services is usually responsible for Section C - BIMs Interview and Section D - PHQ-9 . All interviews should be conducted on the day of or the day before the ARD.

Starting the day after the ARD the rest of the MDS, CAAs and Care Planning can be completed. Of course, all items are very important and must be supported by documentation in the medical record, but it is good to know which MDS questions affect PDPM, as they tend to be scrutinized a little more during a survey or audit. These items are:

• B0700 Makes Self Understood

• C0200 - C0500 BIMs

• C0700 Short-Term Memory

• C1000 Cognitive Skills for Daily Decision Making

• D0200 - D0300 PHQ-9

• D0500 - D0600 PHQ9-OV

• E0100A Hallucinations

• E0100B Delusions

• E0200 A Physical Behavioral Symptoms Directed Toward Others

• E0200B Verbal Behavioral Symptoms Directed Toward Others

• E0200C Other Behavioral Symptoms Not Directed Toward Others

• E0800 Rejection of Care

• E0900 Wandering

Behavioral and Psychotropic Medication Monitoring

As discussed in the Admission Process, Social Services plays a critical role in behavior monitoring and psychotropic medication review. Again, several F-tags are dedicated to this topic because overuse of psychoactive medications has become the norm in recent years. The increased use of these medications has also suggested that there are many behaviors exhibited that need to be addressed and managed. Documentation required:

• Any resident and family discussions about medications or behaviors

• Behaviors and diagnoses that support the need for psychotropic medication

• Non-pharmaceutical interventions in place and the resident's response to them

• Resident response to any GDR attempts (Gradual Dose Reductions)

• Changes in behavior or ADLs

Here are some links to the F tags that could be cited for non-compliance. F Tag 740 Behavioral Health Services, F Tag 741 Sufficient/Competent staff-Behavioral Health Needs, F Tag 742 Treatment/Services for Mental/Psychosocial Concerns, F Tag 743 No Pattern of Behavioral Difficulties unless Unavoidable, F Tag 744 Treatment/Services for Dementia, F Tag 745 Medically Related Social Services and F Tag 758 Free From Unnecessary Psychotropic Meds/PRN Use.

Discharge Preparations and Planning

Another hot topic that Social Services is primarily responsible for is Discharge Preparations and Planning. This has become an area of intense focus since VBP (Value Based Purchasing) came into the limelight. Successful discharge planning requires proper preparation of the residents discharge destination (ie ensuring DME is available, timely provision of services, etc.) as well as resident education about their current diagnoses, functional abilities and health status. Many facilities create discharge forms and checklists to ensure all the proper requirements are completed. If your facility doesn't have this for you, be sure to familiarize yourself with the F Tags below and create your own cheat sheet.

One of the biggest omissions I have seen in Discharge Process is failure to provide sufficient notice of discharge. The team has surely discussed discharge dates and the resident may even be looking forward to going home. However, if the NOMNC has not been delivered at least 2 days prior to their discharge, the facility will be liable for any days the resident remains in the facility. If the resident remains in the facility after skilled services end this mistake can add up very quickly! Other required notices would be the ABN for residents remaining in the facility after skilled services end. In the event that a patient appeals the decision to end skilled services a DENC will need to be issued the same day your QIO notifies you of the appeal. Links to CMS.gov for Instructions and the Forms can be clicked above.

F Tag 622 Transfer and Discharge Requirements, F Tag 623 Notice Requirements Before Transfer or Discharge, and F Tag 624 Preparation for Safe and Orderly Transfer or Discharge discuss the requirements necessary to fulfill these regulations.

Case Management Activities

In addition to discharge planning, all other case management activities should also be documented. This will include any type of Medically Related Social Services that are provided. This includes, but is not limited to the following:

• Making Referrals - helping with any services the facility cannot provide

• Advocating - Assisting with assertion of resident rights

• Grievance Management - Assisting with obtaining resolutions to grievances

• Making Arrangements - providing means to clothing or personal items

• Education - Information provided regarding health care options and ramifications

• Assistance with Legal and Financial Matters - Applying for Medicaid or Funeral Planning

Meetings, meetings, meetings

The Social Services Department is a key player in the success of the facility and their role in many of the meetings provides exceptional insight into the residents needs and outcomes. They participate in Daily Stand-Up, Skilled/Medicare Meetings, PDPM, Care Conferences, Quality of Care, Various Committee meetings (falls, psychotropic, skin, etc.), QAPI, and QI or Angel Rounds.

Management of Personalities, Conflicts, Roommate Issues

and All the other Intangibles that go Unnoticed....

I'm sure I'm probably missing some things here, but that is a pretty lengthy list of hard skills that the Social Worker needs to be good at their jobs. But there is something else that is required and it is probably the one thing that actually makes the difference between a good Social Worker and an EXCEPTIONAL Social Worker. And is heart! Whether it's searching for a lost pair of glasses or dentures, listening patiently to a conflict between roommates or going the extra mile to make sure a resident has home cooked meals ready for them when they discharge home, at the end of the day, it is the Social Workers' hearts that make the residents feel cared for and content.

MDS Solutions HQ

Does your facility need Social Services Training? Let MDS Solutions HQ show you where your opportunities are. Whether it’s improved documentation, better survey outcomes or if you have social workers that are new to LTC/Sub-Acute environment training can be done remotely or in person! I specialize in training the IDT in the RAI process, filling MDS openings, training floor nurses to document skilled need, educating revenue capture through the PDPM process, analyzing and creating action plans for QM and 5 star success.

Contact me at:

https://mdssolutionshq.wixsite.com/my-site

MDSSolutionsHQ@gmail.com or 404-309-3013

Vanessa Tyscka founded MDS Solutions HQ after 25+ years of service focused on serving Skilled Nursing Facilities and their residents. During her career she has worked as a Senior Reimbursement Specialist, Regional MDS Director, MDS Coordinator, DON, ADON, Unit Manager, RN, LPN, and CNA. She has worked for large and medium sized corporations and also has consulting experience in standalone and small organizations. She brings a passion of caring and expert knowledge to every facility she visits. To learn more about Vanessa’s experience and services check out her website https://mdssolutionshq.wixsite.com/my-site or visit her LinkedIn page: www.linkedin.com/in/vanessatysckarn

When Vanessa isn’t working she enjoys cooking things she’s never tried before and spending time in the mountains or on a beach.