Los Altos Post-acute

During a review of SS job description titled, Director of Social Services indicated, Administrative Functions: Plan, develop, organize, implement, evaluate and direct the social service programs of the facility.

Refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident.

Ensure social service progress notes are informative and descriptive of the services provided and of the resident's response to the service.

Develop and maintain a community and social services referral file of agencies and organizations that assist residents.

Participate in community planning related to the interests of the facility and the services and needs of the resident and family.

During a review of CM job description, titled Case Manager indicated, Duties and Responsibilities .Identify post-discharge needs such as nursing and therapy services, medical equipment, home modification or activities of daily living (ADLs) assistance.

According to the State Operations Manual, Appendix PP -Long Term Care Facilities, F-F627 - S483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment.

The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.