HEALTH FACILITY SURVEYOR
BASIC PURPOSE:
Positions in this job family are assigned responsibilities
for performing technical licensure, certification surveys, and complaint
investigations for a variety of health facilities; providing consultative and
technical assistance to health facilities and laboratories regarding standards
for patient services and facility operation; and ensuring compliance with
federal and state regulations.
Typical functions:
The functions within this job family will vary by level, but
may include the following:
·
Investigates allegations and makes determinations of
resident/patient/client abuse and neglect; makes determinations of immediate
jeopardy in which immediate corrective action is necessary because a facility
practice has caused, or is likely to cause, serious injury, harm, impairment,
or death to a resident/patient/client; makes determinations of actual harm in
which a facility practice has caused a negative outcome that has compromised
the resident’s/patient’s/client’s ability to maintain and/or reach his/her
highest practicable physical, mental, and psychosocial well being.
·
Recommends action as to certification or licensure renewal,
non-renewal, or termination/revocation; relocates residents/patients/clients in
the event of an administrative order for the emergency relocation of
residents/patients/clients; testifies to inspection findings at hearings or in
court proceedings.
·
Evaluates kitchen and building sanitation for potential
sources of food borne illness and harborage of rodents and insects; makes
evaluations to determine imminent hazards to life or health which warrant the
closure of a facility and/or relocation of residents/patients/clients.
·
Evaluates facility fire safety systems to ensure emergency
plans are sufficient such as fire alarms, smoke sensors, sprinkler systems,
emergency lighting, ventilation, review of disaster plans, and emergency drill
logs using National Fire Protection Association 101, Life Safety Code, 2000
edition.
·
Reviews facility compliance history; conducts entrance
interview with facility administrator or representative providing explanation
for survey and conducts exit interview to discuss problems and deficiencies;
tours interior and exterior physical environment of facilities for required equipment,
supplies, maintenance, water temperature; reviews staffing logs, in-service
programs, and medical records in order to ensure compliance with regulations.
·
Employs sampling methodology to select
residents/patients/clients for in-depth evaluation of the care and service
needs of the residents/patients/clients versus the care and services provided.
·
Interviews residents/patients/clients, family members, and
facility personnel, and others to obtain and document information regarding
residents/patients/clients care and rights violations and/or to respond to
complaints. Makes determinations of
involuntary discharge. Reviews
residents/patients/clients accounts for misappropriation.
·
Evaluates the administration of health facilities to
determine if policies and procedures comply with federal and state statutes and
regulations.
·
Conducts information analysis of survey findings and
decision-making on facility compliance.
·
Completes required forms and reports, which detail
deficiencies noted during facility survey.
·
Provides technical assistance to facilities in areas of
expertise; describes observed deficiencies to appropriate facility staff and
provides consultation relative to improvements needed to comply with
regulations.
LEVEL
DESCRIPTORS:
The Health Facility Surveyor job family consists of four
levels, which are distinguished by the depth and breadth of accountability, the
expertise required to perform assigned duties and the responsibility assigned
for providing leadership and supervision to others. Because of the experience and knowledge required to evaluate
health care systems, entry into this job family is at the career level.
Level I Code: X29A Salary
Band: I
This is the career level of this job family where incumbents
are trained in state and federal survey protocol, regulations, and procedures
for their primary health facility specialty.
In the course of training, incumbents perform professional work
conducting technical licensure, certification, and complaint surveys for
federally certified and/or licensed state health facilities to ensure
compliance with federal and state laws and regulations.
Knowledge,
Skills and Abilities required at this level include
knowledge of administrative and organizational principles and practices
regarding health care facility operations; and of word processing software
applications and computer operations.
Ability is required to read and understand statutory and regulatory
language; to establish and maintain effective working relationships; to exercise
good judgment in evaluating situations and choosing an appropriate course of
action; to interpret and analyze survey findings against statutory and
regulatory requirements; to make decisions; and to organize and communicate
findings, both orally and in writing, in a logical, clear, concise, and
complete manner.
Education
and Experience requirements at this level
consist of a bachelor’s degree in business, public health, hospital or public
administration, behavioral, environmental, or fire safety science and two years
of experience in a health care, developmental disability, public health,
environmental health, fire safety, or domiciliary facility licensure,
certification, accreditation, inspection, or administration; or a bachelor’s
degree which includes a minimum of thirty semester hours in any combination of
physical, natural or biological sciences and two years of experience in health
care, developmental disability, public health, environmental health, fire
safety, or domiciliary facility licensure, certification, accreditation,
inspection, investigation, or administration; or a combination equivalent of
education substituting the completion of a post baccalaureate degree for one
year only of the required experience.
Level II Code: X29B Salary
Band: J
At this level incumbents will be expected to perform
assigned duties at all levels of complexity.
Knowledge,
Skills and Abilities required at this level include
those at Level I plus knowledge of federal and state laws, regulations, and
policies regarding licensure and certification of health care facilities; of
what constitutes immediacy of threat to a client; and of the requirements for
determining culpability of a facility.
Ability is required to observe, document, analyze, and evaluate the
provision of services against the applicable statue and regulation; to employ
the principles and methods of conducting interviews using memory retrieval
methods; to interview residents/patients/clients with diminished mental
capacity, developmental disabilities, and/or acute and chronic medical
conditions; to gather and present findings within a hostile facility
environment while maintaining professional tone and demeanor; to analyze
non-verbal and verbal communications to determine if an interview subject is
omitting information or is being deceptive, and employ techniques for
identifying omissions and deception in written statement; and to distinguish
between the potential for harm and the potential for serious harm.
Education
and Experience requirements at this level
consist of those identified in Level I plus two additional years of qualifying
experience.
At this level incumbents work with the highest degree of
independence and autonomy with minimal review or oversight and may serve as the
team leader.
Knowledge,
Skills and Abilities
required at this level include those identified at Level II plus knowledge of
residents/patients/clients relocation protocols. Ability is required to facilitate the relocation of
residents/patients/clients; to independently perform facility investigations;
to provide individual instruction, encouragement, and guidance to surveyors
while functioning as a preceptor to surveyors in training; and to lead a team
of surveyors in the conduct of a facility survey.
Education
and Experience
requirements at this level consist of those identified in Level II plus two
additional years of qualifying experience.
Level IV Code: X29D Salary
Band: L
This is the leadership level where incumbents provide direct
supervision to a team of surveyors and are responsible for coordination survey
team activities. Incumbents may present
educational training programs to health care facility staff.
Knowledge,
Skills and Abilities
required at this level include those identified in Level III plus knowledge of
supervisory principles and practices; of performance appraisal policies and
procedures; of agency leave and time accounting policies; and of agency
progressive discipline policy. Ability
is required to supervise professional personnel; to provide educational
training for health care professionals within the employee’s field of
specialty; and to schedule surveys for all subordinate staff.
Education
and Experience requirements at this level consist
of those identified in Level III plus two additional years of qualifying
experience.
SELECTIVE QUALIFICATIONS:
The appointing authority may require education or experience
in a particular area.
SPECIAL REQUIREMENTS:
Applicants must be willing and able to fulfill all
job-related travel normally associated with this position.
Where required by the Centers for Medicaid Services,
incumbents will be required to pass the Surveyor Minimum Qualifications Test
within eleven months of employment.