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Health Facility Surveyor

X29

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.

Level III Code: X29C Salary Band: K

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.

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