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Profiles: Health Facilities Surveyor (Statutory Position - USA)

HEALTH FACILITIES SURVEYOR I

Nature of Work
Under general supervision, performs full performance level professional work conducting complex regulatory compliance determinations during inspections of health care facilities including, but not limited to: hospitals, long term care facilities, home health agencies, hospices, residential board and care facilities, personal care homes, ambulatory surgery centers, end stage renal dialysis units, rural health clinics, screening mammography facilities and clinical laboratories. Functioning individually, or as part of a multi disciplinary team, surveys facilities through observation of care and delivery of services, interviews and review of documentation such as policy and procedures, committee meeting minutes, facility operating records, personnel files, training records and patient/resident medical records. Work involves frequent overnight travel (up to 90%). There is considerable dependence on professional judgement in the performance of a survey. The purpose of a survey is to determine compliance of providers/suppliers and State and federal requirements for licensure and/or Medicare/Medicaid certification, and, on occasion, to provide technical assistance to facilities regarding compliance standards and development and implementation of procedures to improve client/patient services. Performs related work as required.

Distinguishing Characteristics
This is the entry level in the series. An employee in this classification would conduct surveys individually or as a member of a multi-disciplinary team. An incumbent would not be expected to act as a team leader or lead worker on a regular, recurring basis.

Examples of Work
Conducts on-site survey of behavioral and medical health care facilities; discusses survey procedures and practices with administrators and department directors.
Observes client/patient care, collects and records objective data, reviews medical and other records, interviews clients/patients in a group or individually, evaluates policy and treatment or therapeutic services to determine accuracy and adequacy of program/service delivery.
Reviews facility operative and management records, committee meeting minutes and related records as well as resident personal funds accounts to determine compliance with regulatory requirements.
Reviews organizational charts, personnel credentials and training records, and policies and procedures to determine appropriate staffing levels and qualifications of staff to perform services.
Tours the facility to evaluate physical environment compliance of areas such as laboratory, patient treatment and living areas, kitchen and pharmacy.
Evaluates social services, activities, recreation and resident rights issues to ensure provision of services and quality of life.
Utilizes laptop computer system to compile, document and record data and to print preliminary findings.
As part of a survey team, discusses areas of non-compliance with team members.

Knowledge, Skills and Abilities
Knowledge of technical health and safety related fields including special education, behavioral health and laboratory services.
Knowledge of medical and behavioral terminology, health care organizations, professional credentially and practice standards and treatment modalities as they relate to one or more of the following: medical, nursing, social, laboratory medicine or science, behavioral health, dietary, pharmaceutical, therapy services and documentation principles related to each.
Knowledge of practices and procedures in medical care administration and health services provision.
Ability to comprehend, interpret and apply complex information and program material.
Ability to work well with a variety of people.
Ability to communicate well, both orally and in writing.
Ability to exercise good judgment in evaluating situations.
Ability to manage time effectively.

Minimum Qualifications
Training:
Graduation from an accredited four-year college or university with a major in nursing, social work, vocational rehabilitation, hospital or health care administration, nutrition, psychology, counseling, medical records management, clinical laboratory or related sciences, recreation, speech, physical or occupational therapies or other related health/social services/educational fields or safety, engineering or architectural design.

Substitution:
Experience as described below will substitute for the required training on a year-for-year basis.
Experience:
Three years of full-time or equivalent part-time paid professional experience in public health, social work, nursing, vocational rehabilitation, hospital administration or related health program, safety, engineering or architectural design.
Substitution:
A Master's degree in one of the above subject areas may substitute for one year of the required experience.

Note: If employed in the Long Term Care Program of the Office of Health Facility Licensure and Certification, must participate in the required training and testing program in survey and certification techniques.

 

 

HEALTH FACILITIES SURVEYOR II

Nature of Work
Under general supervision, performs advanced level professional work conducting complex regulatory compliance determinations during inspections of health care facilities including, but not limited to: hospitals, long term care facilities, home health agencies, hospices, residential board and care facilities, personal care homes, ambulatory surgery centers, end stage renal dialysis units, rural health clinics, screening mammography facilities and clinical laboratories. Functioning as team leader of a disciplinary team, surveys facilities through observation of care and delivery of services, interviews and review of documentation such as policy and procedures, committee meeting minutes, facility operating records, personnel files, training records and patient/resident medical records. Work involves frequent overnight travel (up to 90%). There is considerable dependence on professional judgement in the performance of a survey. The purpose of a survey is to determine compliance of providers/suppliers and State and federal requirements for licensure and/or Medicare/Medicaid certification, and, on occasion, to provide technical assistance to facilities regarding compliance standards and development and implementation of procedures to improve client/patient services. Functions as a lead worker. Performs related work as required.

Distinguishing Characteristics
This is the advanced level in the series. An employee in this classification would be expected to act as a team leader of a multi-disciplinary survey team and/or as a lead worker on a regular, recurring basis.

Examples of Work
As team leader of a survey team, discusses areas of non compliance with team members, compiles recommendations concerning licensure and/or certification status, edits final reports and reviews corrective measures.
Participates in developing, reviewing and revising health care regulations based on changes in state or federal regulations or studies, submits drafts of proposed changes to various organizations and agencies for comment and discussion.
Conducts on-site survey of behavioral and medical health care facilities; discusses survey procedures and practices with administrators and department directors.
Observes client/patient care, collects and records objective data, reviews medical and other records, interviews clients/patients in a group or individually, evaluates policy and treatment or therapeutic services to determine accuracy and adequacy of program/service delivery.
Reviews facility operative and management records, committee meeting minutes and related records as well as resident personal funds accounts to determine compliance with regulatory requirements.
Reviews organizational charts, personnel credentials and training records, and policies and procedures to determine appropriate staffing levels and qualifications of staff to perform services.
Tours the facility to evaluate physical environment compliance of areas such as laboratory, patient treatment and living areas, kitchen and pharmacy.
Evaluates social services, activities, recreation and resident rights issues to ensure provision of services and quality of life.
Utilizes laptop computer system to compile, document and record data and to print preliminary findings.
Meets with other survey team members to research facility history, review appropriate regulations and to delegate survey duties for each survey, reviews accommodation and travel plans, submits detailed expense and activity reports.

Knowledge, Skills and Abilities
Knowledge of technical health and safety related fields including special education, behavioral health and laboratory services.
Knowledge of medical and behavioral terminology, health care organizations, professional credentially and practice standards and treatment modalities as they relate to one or more of the following: medical, nursing, social, laboratory medicine or science, behavioral health, dietary, pharmaceutical, therapy services and documentation principles related to each.
Knowledge of practices and procedures in medical care administration and health services provision.
Ability to comprehend, interpret and apply complex information and program material.
Ability to work well with a variety of people.
Ability to communicate well, both orally and in writing.
Ability to exercise good judgment in evaluating situations.
Ability to manage time effectively.
Ability to lead co-workers.

Minimum Qualifications [Top]
Training:
Graduation from an accredited four-year college or university with a major in nursing, social work, vocational rehabilitation, hospital or health care administration, nutrition, psychology, counseling, medical records management, clinical laboratory or related sciences, recreation, speech, physical or occupational therapies or other related health/social services/educational fields or safety, engineering or architectural design. If employed in the Long Term Care Program of the Office of Health Facility Licensure and Certification, must have successfully completed the Surveyors and Minimum Qualifications Test (SMQT).
Substitution:
Experience as described below will substitute for the required training on a year-for-year basis.
Experience:
Four years of full-time or equivalent part-time paid professional experience in public health, social work, nursing, vocational rehabilitation, hospital administration or related health program, safety, engineering or architectural design.
Substitution:
A Master's degree in one of the above subject areas may substitute for one year of the required experience.

Established: 12/19/96
Revised: 1/06/98
Effective: 1/1/97; 1/06/98


HEALTH FACILITIES SURVEYOR II

POSITION CODE: 18012

Effective Date: 6-1-00

DISTINGUISHING FEATURES OF WORK:

Under direction, independently or as a member of a professional team, conducts and coordinates state licensure, Medicare or Medicaid certification surveys, investigations, inspections of care and reinspections of health facilities in accordance with state and federal laws and guidelines; explains related laws, deficiencies and violations to owners and operators of health facilities, conducts exit interviews and recommends appropriate corrective measures; recommends and assists supervisor with necessary enforcement actions.

ILLUSTRATIVE EXAMPLES OF WORK:

Independently or as a member of a health facility licensure or certification survey team, performs public health inspections and surveys of long-term care facilities, hospitals, state correctional facilities, home health agencies, ambulatory surgical treatment centers, end state renal disease facilities, and child and adult day care facilities in order to determine the level of compliance with state licensure requirements or federal Medicare and Medicaid certification standards and to determine eligibility for licensure or certification; through interview, inspection and other investigative processes, monitors and observes facility conditions and care provided to recipients and evaluates facility progress in meeting plans of correction; discusses deficiencies with other team members, providing leadership in matters concerning the professional discipline specialty area; prepares all necessary survey forms, memoranda, reports of findings and recommendations concerning licensure and certification of health facilities.

Investigates complaints in health facilities concerning patient care or the operation of the facility or agency; prepares reports of complaint findings; reviews the content and significance of survey or investigation findings with operating and management personnel of the facility or agency and recommends methods to develop adequate programs; assists in moving residents to other facilities in decertification or emergency situations; compiles information for license revocation hearings or court proceedings; provides testimony during hearings or court proceedings against non-compliant facilities.

As a team coordinator, coordinates survey or inspection team member assignments; ensures appropriate completion of required records and reports, reviewing survey packages for accuracy, completeness and timeliness; conducts entrance and exit conferences with health facility owners and operators; prepares survey packages for certification and transmittal.

Provides assistance to providers by conducting and participating in pre-planning conferences, on-site visits and workshops; explains and interprets state laws, standards, department rules and regulations, and policies and procedures as they relate to licensure and certification of providers.

Attends staff meetings, inter-agency meetings, professional meetings and workshops as a means of maintaining expertise in the professional discipline area and in concepts applicable to health care facilities.

Performs other duties as required or assigned which are reasonably within the scope of duties enumerated above.

DESIRABLE REQUIREMENTS:

Education and Experience:

Requires successful completion of both state and federal Basic Surveyor Orientation courses and, for positions engaged in long term care surveys, certification of having successfully the Health Care Financing Administrationís Surveyor Minimum Qualifications Training.

Requires one year of experience as a health facilities surveyor.

Additionally requires either:

1) Completion of four years of college with a minimum of 30 semester hours in the physical and/or biological sciences, supplemented by three years of professional experience in environmental health sanitation or in a health care facility;

OR

2) A bachelorís degree in a human services professional field such as sociology, special education, rehabilitation counseling, or psychology, supplemented by one year of experience working directly with persons with mental retardation or other developmental disabilities and an additional three years of professional experience affording knowledge of the problems and needs of mentally retarded individuals and/or those with related conditions; or a masterís degree in a human services professional field, supplemented by one year of experience working directly with persons with mental retardation or other developmental disabilities and an additional one year of professional experience affording knowledge of the problems and needs of mentally retarded individuals and/or those with related conditions;

OR

3) Possession of a valid Illinois certificate as a registered Dietitian and knowledge, skill and mental development equivalent to completion of four years of college, supplemented by a masterís degree in nutrition, dietetics, or food service management and one year of professional experience in nutrition, dietetics, or food service management; preferably requires registration by the American Dietetic Association.

Knowledges, Skills and Abilities

Requires extensive knowledge of the applicable professional specialty discipline, which is either that of an Environmental Health Practitioner, a Dietitian, or a Qualified Mental Retardation Professional.

Requires working knowledge of state and federal laws and regulations governing licensure and certification of health care providers.

Requires working knowledge of acceptable standards of practice in health facilities and professions and the principles related to the delivery of care to patients.

Requires working knowledge of curriculum development, teaching methodologies, techniques, and strategies.

Requires ability to conduct the survey process effectively and efficiently, including the evaluation of the environment, records, and care and service delivered by the health care provider, identifying areas of non-compliance, problems and discrepancies, and determining possible resolution or action.

Requires ability to gather, collate and classify information about data, people or things and to interpret an extensive variety of technical materials in books, journals and manuals.

Requires ability to establish and maintain effective working relationships with professional personnel, supervisors, peers, the general public, and consumers.

Requires ability to communicate effectively, both orally and in writing.

Requires ability to exercise judgment, discretion, and maintain confidentiality during the conduct of the survey process.

Requires ability to travel to health care provider locations to conduct on-site reviews.


HEALTH FACILITY NURSE SURVEYOR II

Nature of Work
Under limited supervision, performs advanced level professional work conducting complex regulatory compliance determinations for Medicare/Medicaid certification and State licensure during inspections and complaint investigations of health care facilities, including but not limited to: hospitals, long term care facilities, home health agencies, hospices, residential board and care homes, personal care homes, ambulatory surgery centers, end stage renal dialysis units, rural health clinics, intermediate care facilities for the mentally retarded, behavioral health group homes, birthing centers, unlicenced and illegal health care operators and schools. Functioning as a registered professional nurse, evaluates the provision of nursing care based on training and experience as a nurse and clinical knowledge of accepted standards of nursing practice; performs advanced assessments of individuals served by these health facilities for appropriateness of nursing and other health services. May function as team leader of a multi disciplinary team or a lead worker. Conducts facility surveys through observation and evaluation of the provision of patient care and other services, interviews, record review including but not limited to: personnel files, patient medical records, facility policy and procedures, patient care protocols, administrative records and committee minutes. Work involves frequent travel. There is considerable dependence on professional judgment in the performance of a survey. Other responsibilities include the provision of technical assistance to health care providers, planning and presenting provider training, regulatory development, participation in various state committees, and acts as a resource to other health facility surveyors and non-nurse program managers regarding nursing and other health related issues. Performs related work as required.

Distinguishing Characteristics
This level is distinguished from the Health Facility Nurse Surveyor I by the responsibility of leading survey teams or functioning as a lead worker.

Examples of Work
Conducts on-site surveys and complaint/abuse investigations in the above referenced health care facilities; discusses survey procedures and practices with administrators, department directors and facility staff.
Assesses and evaluates patients/residents for the accuracy of the facility staff assessments and the appropriateness and efficacy of nursing and related health care provided, i.e.
physical occupational, speech and respiratory therapies, etc.
Evaluates the provision of nursing services based on accepted standards of practice and facility policy and procedure for nursing techniques including but not limited to: emergency care, intravenous therapy, enteral therapy, injections, tracheostomy care, suctioning, infection control procedures including sterile technique and body substance isolation precautions, assessment and special skin care, range of motion, positioning, use of assistive devices and prostheses.
Makes determinations that poor patient/resident outcomes are based on facilities' failure to assess or provide for a medical/nursing need.
Cites statements of deficient practice for identified non compliance relative to nursing and related health care and defends these deficiencies in administrative official hearings.
May function as team leader of a multi-disciplinary team or a lead worker.

Knowledge, Skills and Abilities
Knowledge of technical health and safety related fields including special education, behavioral health and laboratory services.
Knowledge of medical and behavioral terminology, health care organizations, professional credentials and practice standards and treatment modalities as they relate to medical, nursing, laboratory medicine or science, behavioral health, pharmaceutical, and documentation principles related to each.
Knowledge of practices and procedures in medical care administration and health services provision.
Ability to comprehend, interpret and apply complex information and program material.
Ability to work well with a variety of people.
Ability to communicate well, both orally and in writing.
Ability to exercise good judgment in evaluating situations.
Ability to manage time effectively.
Ability to lead co-workers.

Minimum Qualifications [Top]
Training:
Baccalaureate degree in nursing from an accredited four-year college or university and four years of full-time or equivalent part-time paid experience as a registered professional nurse.
OR
Successful completion of an associate degree from an accredited college or university or a diploma nursing program and five years of full-time or equivalent part-time paid experience as a registered professional nurse.
OR
Professional certification from a recognized national nursing certifying organization as a nurse or nurse practitioner in the area of assignment and four years of full-time or equivalent part-time experience as a registered professional nurse.
OR
Successful completion of an associate degree in nursing from an accredited college or university or a diploma nursing program; plus baccalaureate degree in the health sciences or behavioral sciences and four years of full-time or equivalent part-time paid experience in nursing.
OR
Master's degree in nursing from an accredited four-year college or university and three years of full-time or equivalent part-time paid experience in nursing.

Special Requirement:
Current West Virginia licensure or temporary permit to practice as a registered professional nurse.

NOTE: If employed in the Long Term Care Program of the Office of Health Facility Licensure and Certification, one must have successfully completed the required training in survey and certification techniques and the Surveyors Minimum Qualifications Test (SMQT).

Established: 07/15/99
Retitled & Revised: 11/18/99
Effective: 01/1/00


 

HEALTH FACILITY NURSE SURVEYOR I

Nature of Work
Under general supervision, performs advanced level professional work conducting complex regulatory compliance determinations for Medicare/Medicaid certification and State licensure during inspections and complaint investigations of health care facilities, including, but not limited to: hospitals, long term care facilities, home health agencies, hospices, residential board and care homes, personal care homes, ambulatory surgery centers, end stage renal dialysis units, rural health clinics, intermediate care facilities for the mentally retarded, behavioral health group homes, birthing centers, unlicensed and illegal health care operators and schools. Functioning as a registered professional nurse, evaluates the provision of nursing care based on training and experience as a nurse and clinical knowledge of accepted standards of nursing practice; performs advanced assessments of individuals served by these health facilities for appropriateness of nursing and other health services. Conducts facility surveys through observation and evaluation of the provision of patient care and other services, interviews, record review including, but not limited to: personnel files, patient medical records, facility policy and procedures, patient care protocols, administrative records and committee minutes. Work involves frequent travel. There is considerable dependence on professional judgment in the performance of a survey. Other responsibilities include the provision of technical assistance to health care providers, planning and presenting provider training, regulatory development, participation in various state committees, and acts as a resource to other health facility surveyors and non-nurse program managers regarding nursing and other health related issues. Performs related work as required.

Distinguishing Characteristics
This is the entry level in the series. This level does not have responsibility as a team leader or lead worker on a regular, recurring basis.

Examples of Work
Conducts on-site surveys and complaint/abuse investigations in the above referenced health care facilities; discusses survey procedures and practices with administrators, department directors and facility staff.
Assesses and evaluates patients/residents for the accuracy of the facility staff assessments and the appropriateness and efficacy of nursing and related health care provided, i.e.
physical occupational, speech and respiratory therapies, etc.
Evaluates the provision of nursing services based on accepted standards of practice and facility policy and procedure for nursing techniques including but not limited to: emergency care, intravenous therapy, enteral therapy, injections, tracheostomy care, suctioning, infection control procedures including sterile technique and body substance isolation precautions, assessment and special skin care, range of motion, positioning, use of assistive devices and prostheses.
Makes determinations that poor patient/resident outcomes are based on facilities' failure to assess or provide for a medical/nursing need.
Cites statements of deficient practice for identified non compliance relative to nursing and related health care and defends these deficiencies in administrative official hearings.

Knowledge, Skills and Abilities
Knowledge of technical health and safety related fields including special education, behavioral health and laboratory services.
Knowledge of medical and behavioral terminology, health care organizations, professional credentials and practice standards and treatment modalities as they relate to medical, nursing, laboratory medicine or science, behavioral health, pharmaceutical, and documentation principles related to each.
Knowledge of practices and procedures in medical care administration and health services provision.
Ability to comprehend, interpret and apply complex information and program material.
Ability to work well with a variety of people.
Ability to communicate well, both orally and in writing.
Ability to exercise good judgment in evaluating situations.
Ability to manage time effectively.
Ability to lead co-workers.

Minimum Qualifications [Top]
TRAINING and EXPERIENCE:
Baccalaureate degree in nursing from an accredited four-year college or university and three years of full-time or equivalent part-time paid experience as a registered professional nurse.
Successful completion of an associate degree from an accredited college or university or a diploma nursing program and four years of full-time or equivalent part-time paid experience as a registered professional nurse.
OR
Professional certification from a recognized national nursing certifying organization as a nurse or nurse practitioner in the area of assignment and three years of full-time or equivalent part-time experience as a registered professional nurse.
OR
Successful completion of an associate degree in nursing from an accredited college or university or a diploma nursing program; plus baccalaureate degree in the health sciences or behavioral sciences and three years of full-time or equivalent part-time paid experience in nursing.
OR
Master's degree in nursing from an accredited four-year college or university and two years of full-time or equivalent part-time paid experience in nursing.

Special Requirement:
Current West Virginia licensure or temporary permit to practice as a registered professional nurse.

Established: 11/18/99
Effective: 01/01/00


 

HEALTH FACILITIES SURVEYOR I

POSITION CODE: 18011

Effective Date: 6-1-00

DISTINGUISHING FEATURES OF WORK:

Under general supervision, carries out progressively responsible inspections, surveys and reinspections in accordance with state and federal laws and guidelines, explaining related laws and outlining violations; as a team member, participates in the conduct of investigations and exit interviews with health facility providers; receives instruction and on-the-job training in the conduct of state licensure, Medicare or Medicaid certification surveys and inspections of care of health care facilities.

The Health Facilities Surveyor I is the entry level of this series, where incumbents participate in inspections, surveys and reinspections as team members. In contrast, the Health Facilities Surveyor II is designed for those positions that are additionally responsible for coordinating the work of Health Facilities Surveyor team members and independently performing Health Facilities Surveyor work when the presence of a team is not required.

ILLUSTRATIVE EXAMPLES OF WORK:

Participates in and completes agency sponsored and federal training programs to develop professional skills and knowledge of applicable rules and regulations concerning licensure standards and conditions of participation in Medicare and Medicaid programs for health facilities providing long term care or those providing associated services for people with mental retardation and developmental disabilities; through study of licensing and certification laws, regulations, policies and procedures, learns applicable principles and statutes used by health facility surveyors.

As a member of a health facility licensure or certification survey team, performs public health inspections and surveys of long-term care facilities, hospitals, state correctional facilities, home health agencies, ambulatory surgical treatment centers, end state renal disease facilities, and child and adult day care facilities to determine the level of compliance with state licensure requirements and federal Medicare and Medicaid certification standards; through interview, inspection and other investigative processes, monitors and observes facility conditions and care provided to recipients and evaluates facility progress in meeting plans of correction; reports unusual situations and problems to the team leader or supervisor for consideration and disposition; documents findings, discusses deficiencies with other team members, and prepares all necessary survey forms, memoranda, reports of findings and recommendations concerning licensure and certification of health facilities.

As a team member, assists in investigating complaints in health facilities concerning patient care or the operation of the facility or agency; discusses complaint findings with other team members and prepares related reports; reviews the content and significance of findings with operating and management personnel of the facility or agency and recommends methods to develop adequate programs; assists in moving residents to other facilities in decertification or emergency situations.

As a team member, provides assistance to providers by participating in pre-planning conferences, on-site visits and workshops; explains and interprets laws, standards, rules, regulations, policies and procedures related to licensure and certification of health facilities.

Attends staff meetings, inter-agency meetings, professional meetings and workshops as a means of maintaining expertise in the professional discipline area and in concepts applicable to health care facilities.

Performs other duties as required or assigned which are reasonably within the scope of duties enumerated above.

DESIRABLE REQUIREMENTS:

Education and Experience:

Requires completion of four years of college with a minimum of 30 semester hours in the physical and/or biological sciences, supplemented by one year professional experience in environmental health sanitation or in a health care facility.

OR

Requires a bachelorís degree in a human services professional field such as sociology, special education, rehabilitation counseling, or psychology, supplemented by one year of experience working directly with persons with mental retardation or other developmental disabilities and an additional two years of professional experience affording knowledge of the problems and needs of mentally retarded individuals and/or those with related conditions; or a masterís degree in a human services professional field and one year of experience working directly with persons with mental retardation or other developmental disabilities.

OR

Requires knowledge, skill and mental development equivalent to completion of four years of college, supplemented by a masterís degree in nutrition, dietetics, or food service management, preferably including registration by the American Dietetic Association and possession of a valid Illinois certificate as a registered Dietitian.

Knowledges, Skills and Abilities

Requires working knowledge of the applicable professional specialty discipline, which is either that of an Environmental Health Practitioner, a Dietitian, or a Qualified Mental Retardation Professional.

Requires working knowledge of acceptable standards of practice in health facilities and professions and the principles related to the delivery of care to patients.

Requires working knowledge of curriculum development, teaching methodologies, techniques, and strategies.

Requires ability to satisfactorily complete state and federal training concerning laws and regulations governing licensure, Medicare/Medicaid certification and inspections of health care facilities and/or to obtain federal Surveyor Minimum Qualification Training certification.

Requires ability to conduct the survey process effectively and efficiently, including the evaluation of the environment, records, and care and service delivered by the health care provider, identifying areas of non-compliance, problems and discrepancies, and determining possible resolution or action.

Requires ability to gather, collate and classify information about data, people or things and to interpret an extensive variety of technical materials in books, journals and manuals.

Requires ability to establish and maintain effective working relationships with professional personnel, supervisors, peers, the general public, and consumers.

Requires ability to communicate effectively, both orally and in writing.

Requires ability to exercise judgment, discretion, and maintain confidentiality during the conduct of the survey process.

Requires ability to travel to health care provider locations to conduct on-site reviews.

 


HEALTH FACILITIES SURVEYOR III

POSITION CODE: 18013

Effective Date: 6-1-00

DISTINGUISHING FEATURES OF WORK:

Under general direction, independently or as a member of a professional team, serves at the expert level by regularly performing the most difficult and complex assignments associated with state licensure, Medicare or Medicaid certification surveys, investigations, inspections of care and reinspections of health facilities; regularly conducts and coordinates surveys, investigations, and inspections of facilities with severe problems, such as those where certification or licensure revocation proceedings or other legal action is probable; serves as a preceptor for lower level surveyors.

ILLUSTRATIVE EXAMPLES OF WORK:

Independently or as a member of a health facility licensure or certification survey team, performs public health inspections and surveys of long-term care facilities, hospitals, state correctional facilities, home health agencies, ambulatory surgical treatment centers, end state renal disease facilities, and child and adult day care facilities, regularly including those facilities that are experiencing severe problems in complying with state licensure requirements or federal Medicare and Medicaid certification standards and/or where probable fraud exists; through interview, inspection and other investigative processes, monitors and observes facility conditions and care provided to recipients; evaluates the need for legal action and facility progress in meeting plans of correction; prepares all necessary survey forms, memoranda, reports of findings and recommendations concerning licensure and certification of health facilities; discusses deficiencies with other team members, providing leadership in survey techniques and the professional specialty discipline.

Investigates complaints in health facilities concerning patient care or the operation of the facility or agency; prepares reports of complaint findings; reviews the content and significance of survey or investigation findings with operating and management personnel of the facility or agency and recommends methods to develop adequate programs; assists in moving residents to other facilities in decertification or emergency situations; compiles information for license revocation hearings or court proceedings; provides expert testimony during hearings or court proceedings against non-compliant facilities.

As a preceptor to new surveyors, conducts training for purposes of initial orientation and continued development, including such topics as different provider types or changes in regulations and survey techniques; monitors performance of new surveyors and provides feedback to the supervisor; recommends changes in survey procedure, orientation or training materials, and other policies and procedures.

As a team coordinator, coordinates survey or inspection team member assignments; ensures appropriate completion of required records and reports, reviewing survey packages for accuracy, completeness and timeliness; conducts entrance and exit conferences with health facility owners and operators; prepares survey packages for certification and transmittal.

Provides assistance to providers by conducting and participating in pre-planning conferences, on-site visits and workshops; explains and interprets state laws, standards, department rules and regulations, and policies and procedures as they relate to licensure and certification of providers.

Attends staff meetings, inter-agency meetings, professional meetings and workshops as a means of maintaining expertise in the professional discipline area and in concepts applicable to health care facilities.

Performs other duties as required or assigned which are reasonably within the scope of duties enumerated above.

DESIRABLE REQUIREMENTS:

Education and Experience:

Requires successful completion of both state and federal Basic Surveyor Orientation courses and, for positions engaged in long term care surveys, requires certification of having successfully completed federal Surveyor Minimum Qualifications Training.

Requires three years of experience as a health facilities surveyor

Additionally requires either:

Completion of four years of college with a minimum of 30 semester hours in the physical and/or biological sciences, supplemented by three years of professional experience in environmental health sanitation or in a health care facility; preferably requires possession of an Environmental Health Practitioner license valid in Illinois.

OR

2) A bachelorís degree in a human services professional field such as sociology, special education, rehabilitation counseling, or psychology, supplemented by one year of experience working directly with persons with mental retardation or other developmental disabilities and an additional three years of professional experience affording knowledge of the problems and needs of mentally retarded individuals and/or those with related conditions; or a Masterís degree in a human services professional field, supplemented by one year of experience working directly with persons with mental retardation or other developmental disabilities and an additional one year of professional experience affording knowledge of the problems and needs of mentally retarded individuals and/or those with related conditions;

OR

3) Possession of a valid Illinois certificate as a registered Dietitian and knowledge, skill and mental development equivalent to completion of four years of college, supplemented by a Masterís degree in nutrition, dietetics, or food service management and one year of professional experience in nutrition, dietetics, or food service management; preferably requires registration by the American Dietetic Association.

Knowledges, Skills and Abilities

Requires thorough knowledge of the applicable professional specialty discipline, which is either that of an Environmental Health Practitioner, a Dietitian, or a Qualified Mental Retardation Professional.

Requires extensive knowledge of state and federal laws and regulations governing licensure and certification of health care providers.

Requires extensive knowledge of acceptable standards of practice in health facilities and professions and the principles related to the delivery of care to patients.

Requires working knowledge of curriculum development, teaching methodologies, techniques, and strategies.

Requires working knowledge of investigation and interrogation techniques, such as might be obtained through completion of police officer training.

Requires ability to satisfactorily complete training concerning state and federal law and regulations governing licensure and Medicare/Medicaid certification of health care facilities.

Requires ability to conduct the survey process effectively and efficiently, including the evaluation of the environment, records, and care and service delivered by the health care provider, identifying areas of non-compliance, problems and discrepancies, and determining possible resolution or action.

Requires ability to gather, collate and classify information about data, people or things and to interpret an extensive variety of technical materials in books, journals and manuals.

Requires ability to establish and maintain effective working relationships with professional personnel, supervisors, peers, the general public, state and local police, and consumers.

Requires ability to communicate effectively, both orally and in writing.

Requires ability to exercise judgment, discretion, and maintain confidentiality during the conduct of the survey process.

Requires ability to travel to health care provider locations to conduct on-site reviews.


HEALTH FACILITIES SURVEYOR

DEFINITION

Surveys and evaluates health care/treatment facilities to determine degree of compliance with departmental, state, and/or federal standards for a health facility or organization licensed by the state or certified by the government and documents all deficiencies noted; performs related work as required.

The Work Examples and Competencies listed are for illustrative purposes only and not intended to be the primary basis for position classification decisions.

WORK EXAMPLES

Analyzes all facets of facility care; determines whether licensure is required and the degree of conformance with departmental, state and federal laws, rules, and regulations pertaining to certified and licensed health care/treatment facilities.

Reviews services to assure that resident's needs are met in areas of personal health and hygiene, clothing, nutrition, activities of daily living, restorative nursing, sanitation of personal care, equipment and supplies, proper use of protective devices, documentation of vital signs, implementation of physicians orders, staff work assignments, care plans, and nursing policies and procedures.

Reviews medical/treatment records to determine if interdisciplinary documentation shows adequate care is rendered and maintained.

Reviews all administrative by-laws, policies and procedures of the facility to assure that they meet the needs of the facility and resident care.

Examines facility staffing and consultant qualifications through documentation pertaining to such things as payroll, census, agreements and records to determine that adequate number of qualified persons are employed.

Checks storage, handling and administration of drugs and biologicals to verify compliance with state and federal requirements.

Evaluates the food service department to assure that proper nutritional needs of residents are met and proper sanitation conditions are maintained.

Observes laundry, housekeeping, and maintenance to assure that environmental conditions conform to departmental rules and regulations by checking rooms, storage, kitchen, bathroom, maintenance and treatment areas.

Completes survey materials to substantiate findings; documents detailed facts related to deficiencies; submits written reports to inform supervisor of status of facility where non-compliance is found.

Elicits information not otherwise available by interviewing staff, residents, relatives of residents, and other appropriate individuals; testifies in court cases or hearings to present evidence or verify information.

Documents facts from records, observations and interviews during complaint investigations for written reports and necessary follow-ups on justified complaints; obtains supporting evidence of deficiencies (e.g., photos), photocopies of records and policies, and written notes from interviews.

Recommends certification, certification with correctable deficiencies, non-certification, fines/citations, an immediate full survey, ways to correct deficiencies, or referral to another agency; encourages correction of deficiencies or informs Health Care Financing Administration; cites violation and corresponding class and fine, completion date for plan of correction, and submits supportive documentation.

COMPETENCIES REQUIRED

Knowledge of health care standards and state and federal rules and regulations necessary for certification or licensure of a health care/treatment facility and/or program operations.

Knowledge of modern nursing or pharmacy practices, health care administration or dietetics, equipment and techniques relative to resident care.

Knowledge of the current literature, trends, and developments in the field of nursing, nutrition, pharmacy, and/or substance abuse as it relates to surveying and improving licensed health care facilities or programs.

Knowledge of interviewing skills and techniques in order to obtain pertinent information during inspections.

Knowledge of applicable state and federal regulations regarding laboratory certification, appraisal and/or testing.

Ability to recognize deficiencies in all health care/treatment service and recommend corrective procedures.

Ability to exercise professional judgment in analyzing all matters related to licensed health care/treatment facilities.

Ability to be tactful and diplomatic in stressful situations.

Ability to interact with physicians, nurses, administrators, and other professionals to establish and maintain a professional working relationship with them.

Displays high standards of ethical conduct. Exhibits honesty and integrity. Refrains from theft-related, dishonest or unethical behavior.

Works and communicates with internal and external clients and customers to meet their needs in a polite, courteous, and cooperative manner. Committed to quality service.

Displays a high level of initiative, effort and commitment towards completing assignments efficiently. Works with minimal supervision. Demonstrates responsible behavior and attention to detail.

Responds appropriately to supervision. Makes an effort to follow policy and cooperate with supervisors.

Aligns behavior with the needs, priorities and goals of the organization.

Encourages and facilitates cooperation, pride, trust, and group identity. Fosters commitment and team spirit.

Expresses information to individuals or groups effectively, taking into account the audience and nature of the information. Listens to others and responds appropriately.

EDUCATION, EXPERIENCE AND SPECIAL REQUIREMENTS

Completion of an educational program in professional Nursing and registration as a nurse or graduation from an accredited college or university with a Bachelorís degree with a concentration of study in a human services area (e.g., psychology, sociology, gerontology, anthropology, therapeutic recreation, rehabilitation, or a similar area related to provisions of services) and experience equal to three years of full-time professional work;

OR

completion of a Pharmacy degree, a Masterís degree, or advanced degree above the Masterís level in a human services area at an accredited college or university, and experience equal to one year of full-time professional work;

OR

graduation from an accredited college or university and three years work experience in health administration; in a clinical substance abuse program; or in a regulatory program which involves the surveying and evaluating of situations, conditions and operating procedures of health care/treatment facilities;

OR

certification as a rehabilitation counselor by the Commission on Rehabilitation Counselor Certification plus specialized training or experience equal to one year of full-time professional work in a nursing, treatment, or habilitation program for mentally retarded clients;

OR

an equivalent combination of education and experience substituting one year of the above specified experience for one year of the required education;

OR

thirty semester hours of graduate course work in public, business or health administration, in the health field or social work, counseling, or rehabilitation from an accredited college or university may be substituted for each year of experience to a maximum substitution of two years.

NOTE

Applicants possessing licensure, certification, registration or degree should indicate such on the application form and may be required to provide proof at the time of interview.

Licensure or temporary licensure by the State of Iowa is required for designated positions in this class. Applicants who now possess a current valid license from another state need not have an Iowa license to apply, but will be required to obtain the appropriate Iowa license prior to beginning actual employment.

For purposes of qualifying for this job class, "professional experience" shall be indicated by having responsibility for assessment and diagnosis of client problems and needs, developing a plan of treatment, evaluating client progress toward meeting treatment goals, modifying treatment objectives, etc. Work at this level requires a prerequisite of post high school educational training or certification in the behavioral, social, health sciences, or health administration.

SELECTIVE CERTIFICATION

For certain designated positions, the appointing authority, with Department of Personnel approval, may selectively request those applicants possessing a minimum of twelve semester hours of education or six months of experience or a combination thereof in one of the following:

098 clinical substance abuse program (Direct Treatment Services)

268 health administration

872 registered nurse

582 registered nurse in a hospital setting

583 registered nurse in a long term care setting

584 registered nurse in a home care setting

550 pharmacist

899 registered dietician

580 Qualified Mental Retardation Professional (QMRP) (Applicant must meet federal requirements for being a QMRP - Registration as a Nurse or a minimum of a Bachelorís Degree with a concentration of study in a human services area (e.g., Psychology, sociology, gerontology, anthropology, etc.) and at least one year of direct hands-on experience working with people who have mental retardation.

581 Social Worker (Applicant must meet Social Worker 6 qualifications - Graduation from an accredited college or university: 1) Any degree + 6 years of full-time experience in a social work capacity in a public or private agency; 2) BSW + five years in a social work capacity; 3) MSW + 3 years in a social work capacity; 4) an equivalent combination of education and experience listed above; permanent full-time state employees with DHS social work experience may qualify with one year less experience.

Effective Date: 4/00 DGL