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Clinical Health Facility Surveyor

X46

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; evaluating the care provided residents/patients/clients by licensed or registered facility staff; and providing consultative and technical assistance to health facilities and laboratories regarding professional standards of practice; and ensuring compliance with federal and state laws and regulations.

Typical Functions

The functions within this job family will vary by level, but may include the following:

  • Based on the licensed or registered professional status of the incumbents applies knowledge of professional standards of practice to observe, analyze, and evaluate the provision of nursing, dietary, social, laboratory, and pharmaceutical services as well as respiratory, speech, physical and occupational therapy services for adherence to professional standards of practice.
  • 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, and sanitation; evaluates administrative records to include policies and procedures, 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/or to respond to complaints.
  • Evaluate the administration of health facilities to determine if policies and procedures comply with federal and state statutes and regulations.
  • Completes required forms and reports, which detail deficiencies noted during facility survey.
  • 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 cause 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.
  • 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 Clinical 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 the provision of clinical and laboratory services provided by licensed or registered health care professionals, entry into this job family is at the career level.

Level I Code: X46A Salary Band: J

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 federal and state health facilities to ensure compliance with federal and state laws and regulations.

Knowledge, Skills and Abilities required at this level include knowledge of the principles, practices, and ethics for the incumbent’s licensed or registered professional status; of administrative and organizational principles and practices regarding health care facility operations; of the principles of interviewing; 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 registration as a Medical Technologist with the American Society of Clinical Pathologists, plus two years experience as a Registered Medical technologist; or a bachelor’s degree and possession of a valid permanent Oklahoma license as a medical practitioner issued by the Oklahoma Board of Medical Licensure, plus two years of professional experience as a licensed medical practitioner; or possession of a valid permanent Oklahoma license as a social worker issued by the Oklahoma State Board of Licensed Social Workers, plus two years of professional experience as a licensed social worker; or possession of a valid permanent Oklahoma license as approved by the Oklahoma Board of Nursing to practice  practical nursing, or, Licensed Practical Nurse License recognized by the Enhanced Nurse Licensure Compact (eNLC) and four years of experience as a licensed practical nurse in a health care setting; or possession of a valid permanent Oklahoma license as approved by the Oklahoma Board of Nursing to practice professional nursing, or, Licensed Practical Nurse License recognized by the Enhanced Nurse Licensure Compact (eNLC) and three years of experience as a registered nurse or a bachelor’s degree in nursing and two years of experience as a registered nurse; 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: X46B Salary Band: K

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 care against the applicable standards of practice, 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.

Level III Code: X46C Salary Band: L

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: X46D Salary Band: M

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 to licensed or registered health care professionals within the employee’s licensed or registered 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.

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.

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