Welcome Interns to Hearthstone SN Health Center

Welcome to your internship at Hearthstone SN Health Center!

This internship is what you make it. So make the most of it!



How Familiar are you with Skilled Nursing Facilities?

  • Very Familiar
  • Somewhat Familiar
  • Not Familiar At All

Your Role as an Intern

First thing first: WELCOME!!

We are happy to have you here and to be a part of our Hearthstone family. This internship is a great learning experience but it is ultimately up to you what you learn and how much you learn. Consider your goals and expectations from this internship and your field instructor/supervisor. This course is a basic orientation of a social worker's role/duties at Hearthstone. Please review your Social Work Intern Manual for more in-depth descriptions and resources. But, don't forget your most important resource; YOUR FIELD INSTRUCTOR! If you have any questions or concerns your best resource is your supervisor, they are here to help and guide you. Don't be afraid to ask questions.

What is a Skilled Nursing Facility?

What is a Skilled Nursing Facility (SNF)?

A Skilled Nursing Facility (SNF) is a clinical care provider offering 24-hour licensed nursing care. An SNF primarily provides services for residents requiring medical and nursing care and/or therapy services for rehabilitation. A licensed physician supervises each patient’s care and a nurse or other medical professional is always on-site. Other medical professionals such as occupational or physical therapists are also available. Care typically includes: physical therapy, occupational and speech rehabilitation, intravenous therapy, post-surgical stabilization, pulmonary management, and wound care. Also, an SNF provides assistance with administration of medications and aids in a variety of daily living needs including dressing, bathing, walking, and eating.

Senior Care Centers: Company Profile

Senior Care Centers believes every patient and resident should be treated with the dignity and respect they deserve while receiving the clinical care that meets their needs. We are committed to providing patients with compassionate care throughout their stay. With over 100 locations across Texas and Louisiana, Senior Care Centers offers a range of skilled nursing services including: short-term rehabilitation, long-term care, memory care, assisted living and independent living. The heart of nursing care is here.

Senior Care Centers: Values

Company Values


Integrity is doing the right thing every time no matter what. At Senior Care Centers, we promote high moral and ethical standards. We are accepting of individuals from all walks of life and we value their diverse backgrounds and ideas. We earn the trust of our clinical teams and business partners through our decisive actions and accountability for upholding our values. We respond with a sense of urgency to the concerns of others and listen to honest and open feedback.


Growth is the continuous improvement of personal, professional and organization goals. Our company fosters participation in personal and professional development. We demonstrate a willingness to change and learn from past success and failures, and we consistently take personal responsibility for improvements of systems, policies, and procedures.


We believe in treating others in a caring, kind, and truthful manner in ALL circumstances. We practice caring and courageous coaching (CCC). We listen first to understand and acknowledge others with a smile and eye contact. We endeavor to exemplify a gracious and polite attitude at all times.


Excellence is made possible when each individual, team, and our organization is a role model of the highest standard of clinical, operational, and financial performance. This includes: treating every patient as our own; identifying opportunities to improve the experience of team members, patients, families and communities; acting with a sense of urgency for the safety of team members and patients; pursuing continuous improvement of clinical, operational, and financial best practices; building trust with team members, patients, families and communities by being consistently reliable.


Wellness is wholeness of mind, body, and spirit to achieve a balance of personal, organizational, and community well-being. We’ll help those in our care achieve wellness by demonstrating positive choices regarding healthy life styles; creating, participating, and supporting a dynamic wellness communication plan; participating in wellness programs to establish industry standards; and supporting programs that enhance the Quality of Life for our team members, patients, and communities.

Senior Care Centers: Services Provided

Services Provided

  • Independent Living 
  • Short-Term Care
  • Long-Term Care
  • Assisted Living
  • Rehabilitation
  • Palliative Care 
  • Out Patient Care
  • Memory Care
  • Pulmonary & Ventilator Unit Care
  • Cardiac Care
  • Wound Care Management
  • Diabetes Care
  • Stroke Recovery
  • Specialized Nutrition Program

Senior Care Centers: Social Services

Where Does the Social Worker Need to be, on a Weekly Basis?


 9:00- Morning Meeting

 12:00- Rehab Meeting with therapy.


 9:00- Morning Meeting

 12:00- IDT Meeting with ADON, DOR, and MD.

 1:00- Lunch


 9:00- Morning Meeting

 11:00- Managed Care Meeting with ADON and                       DOR. 


9:00- Morning Meeting

10:00- Care Plan Meetings

12:00- Lunch. Make sure to eat!


9:00- Morning Meeting

12:00- Lunch.

Social Services: Duties of a Social Worker

Duties of a Social Services Director

  • Meet with staff in planning social services
  • Advocates daily on behalf of all residents
  • Reports abuse, neglect or exploitation
  • Maintains professional working rapport 
  • Consistently abides by Social Work Code of Ethics 
  • Completes Social Service History and Social Service Evaluation
  • Completes sections on MDS 3.0 
  • Educates, reviews and assists residents in completing Advance Directives, Medical Power of Attorney, Out of Hospital Do Not Resuscitate documents
  • Prepares care plans including: Advance Directives, DNR, resident personal preferences, behavioral/psychosocial issues
  • Maintains knowledge of federal and state regulations for long-term care facilities
  • Facilitates referrals to ancillary services
  • Educates/ communicates with residents and/or responsible parties about Palliative Care vs. Hospice Care and assists in the referral/transition process
  • Procures prior authorization numbers for residents with Medicaid who require ambulance transportation to non-emergency medical appointments
  • Prepares a Social Service Evaluation prior to each resident’s care plan to assess changes/areas of need since their last care plan
  • Documents interactions with residents and/or responsible parties through stay in facility
  • Discharge planning on behalf of residents 
  • Develop and maintain a good working rapport with facility staff and outside community agencies 
  • Facilitates resident room changes 
  • Reviews resident’s psychosocial well-being as needed
  • Attends Resident Council meetings only if invited 
  • Facilitates proper procedure on initiation/completion of Grievance Reports and assists in maintaining the facility Monthly Grievance Log
  • Attends and provides quarterly information for Performance Improvement/Quality Assurance meetings 
  • Attends Standards of Care meetings and follow up on any Social Work issues discussed
  • Performs bi-annual reviews of all resident charts 
  • Keeps up to date with current federal and state regulations, professional standards, and makes recommendations for changes in policies and procedures to the department director or Administrator

Know Your Limitations

Know Your Limitations

If you feel unsure if you have the authority or duty or do not feel comfortable answering someone's question; It is okay to say "I do not know. I can help you find someone that might know the answer." Stay within your level of competence. You are not a medical professional. There are medical professionals in the building, refer residents/family members to these professionals when necessary. 

A resident has a questions concerning his/her diagnosis and asks you if you have access to their diagnosis sheet. The resident lets you know that they are confused about what diagnosis they have and what they mean. How do you respond?

  • Let the resident know their diagnosis based off their diagnosis sheet on PCC and describe their diagnosis to the best of your ability
  • Let the resident know that you are not the most appropriate for this question and refer them to the doctor and nurse practitioner for a better and more appropriate response.
  • Consider the common diagnosis found in senior nursing facilities and let the resident know they probably have one of those diagnosis and then describe each diagnosis.

A resident has a questions concerning his/her discharge planning and states he/she is worried about not having the necessary medical equipment when they get home. How do you respond?

  • Tell resident you are not the most appropriate person for this question and they should ask the CNAs about discharge planning
  • Let the resident know that Hearthstone does not help with discharge planning, refer them to Amazon.com, and wish them the best of luck.
  • Inform the resident of the duties of a social worker and that the social worker will be assisting the resident in discharge planning and acquiring Durable Medical Equipment (DME)
  • Tell the resident you will back to them and send an email out to Admissions, Nursing, and the Administrator tell them that a resident needs medical equipment,

Which is a role of a social worker at Hearthstone SN Health Center?

  • Organizing activities for residents
  • Administering NOMNCs
  • Administering medications to residents
  • Advocate for residents

What do I need to know?

Medicare vs Medicaid

Medicare is a federal program that provides health coverage if you are 65 or older, have a severe disability, dialysis patients, no matter your income. Medicaid is a state and federal program that provides health coverage to low income people and varies from state to state.


Medicare is our country's health insurance program for people age 65 or older, who are citizens or permanent residents of the United States. People younger than 65 with certain disabilities, or permanent kidney failure, or ALS, can also qualify for Medicare. 


Medicaid is a healthcare program that assists low-income families or individuals in paying for long-term medical and custodial care costs. Medicaid is a joint program, funded primarily by the federal government and run at the state level, where coverage may vary. 


Medicare has FOUR parts.

  • Medicare Part A (Hospital Insurance): helps pay for inpatient care in a hospital, SNF (post hospital), and some HHC, and hospice care.
  • Medicare Part B (Medical Insurance): helps  pay for services from doctors and other health care providers, outpatient care, home health care (HHC), durable medical equipment (DME), and some preventative services.
  • Medicare Part C (Medicare Advantage) includes all benefits and services covered under Part A and Part B. Some plans include Medicare prescription drug coverage (Medicare Part D) and other extra benefits and services. 
  • Medicare Part D (Medicare prescription drug coverage) helps cover the cost of prescription drugs.


List of Medicaid Benefits

The list below outlines mandatory Medicaid benefits, which states are required to provide under federal law, and optional benefits that states may cover if they choose.

Mandatory Benefits

  • Inpatient hospital services
  • Outpatient hospital services
  • EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
  • Nursing Facility Services (long term care)
  • Home health services
  • Physician services
  • Rural health clinic services
  • Federally qualified health center services
  • Laboratory and X-ray services
  • Family planning services
  • Nurse Midwife services
  • Certified Pediatric and Family Nurse Practitioner services
  • Freestanding Birth Center services (when licensed or otherwise recognized by the state)
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women

Optional Benefits

  • Prescription Drugs
  • Clinic services
  • Physical therapy
  • Occupational therapy
  • Speech, hearing and language disorder services
  • Respiratory care services
  • Other diagnostic, screening, preventive and rehabilitative services
  • Podiatry services
  • Optometry services
  • Dental Services
  • Dentures
  • Prosthetics
  • Eyeglasses
  • Chiropractic services
  • Other practitioner services
  • Private duty nursing services
  • Personal Care
  • Hospice
  • Case management
  • Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
  • Services in an intermediate care facility for Individuals with Intellectual Disability
  • State Plan Home and Community Based Services- 1915(i) etc.

___________ is a federal insurance program for people 65 or older, with a severe disability, or dialysis patients, no mater your income. This program is separated into four parts.

  • Medicare
  • Medicaid

___________ is a joint state and federal program that provides health coverage to low income people, funded primarily by the federal government and is run at the state level. Coverage varies from state to state.

  • Medicare
  • Medicaid



This an exciting time for learning, and I hope your experience here is a great platform for you to apply what you are learning in class. This course is to help you get acquainted with long-term care facilities, this facility, and a social worker's role here at Hearthstone. As any new placement, there is no way to understand the totality of this internship until you experience it first hand. Best wishes and Enjoy!

What is Your Super Power

What is Your Super Power?



Author, A. A., & Author, B. B. (Date of publication). Title of article. Title of Journal, volume number. Retrieved from http://www.journalhomepage.com/full/url/

Centers for Medicare & Medicaid Services (n.d.) List of Medicaid Benefits. Retrieved from https://www.medicaid.gov/medicaid/benefits/list-of-benefits/index.html

Digital Communications Division (2015). What is the difference between Medicare and Medicaid?. U.S. Department of Health & Human Services. Retrieved from https://www.hhs.gov/answers/medicare-and-medicaid/what-is-the-difference-between-medicare-medicaid/index.html

Social Security Administration (2017). Medicare. Retrieved from https://www.ssa.gov/pubs/EN-05-10043.pdf