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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00110095 |
Description Activated On: 10/27/2022 4:20:48 PM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. This position in the Division of Home Health (HH) supports the Department’s mission of protecting the public health through its responsibility for conducting health care surveys to determine compliance with federal and/or state regulations. This position completes conducts surveys/resurveys of non-profit and profit health care facilities for Medicare certification and/or state licensure/approval programs. Facilities include Medicare-certified home health agencies, hospices, end-stage renal disease facilities, rural health clinics, outpatient physical therapy and/or speech pathology services, comprehensive outpatient rehabilitation facilities, federally qualified health centers, state licensed home health care agencies, birth centers, pediatric extended care centers and the home care agency/home care registry licensure program. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. Demonstrates critical thinking, communication, and professional judgment in work duties such as gathering and documenting survey data, applying regulations to survey findings, and preparing and providing survey reports. Duties include: Demonstrate awareness of the vulnerable populations the organization serves by identifying, providing, and advocating for resources, services, communication methods, and policies that would help those populations achieve health equity. Use information and data available for specific facility to prepare and plan for surveys. Conduct complaint or incident investigations, facility surveys (in office or onsite) and occupancy surveys to fulfill requirements for licensure, relicensure, and/or certification under Medicaid/Medicare requirements. Manages the intake and review of facility/agency applications for initial licensure by DOH and/or initial certification for Medicare. Reviews and ensures that these applications are appropriately completed to ensure compliance with State and Federal regulations. Review emailed reports of need and facility reportable incidents via Event Reporting System for determination of need of follow-up as assigned. Responds to hotline calls for consumer questions and reviews and responds to complaint hotline calls, email, or web-based complaints form to clarify details of complaint allegations. Identifies concerns that are potential violations of State and/or Federal regulations that must be investigated. Inform complainant whether or not the concern is a regulatory violation and about the complaint investigation process. Enters complaint into online system identifying assigned field office and surveyor, prioritizes complaint investigation due date and complaint details. Send formal acknowledgement to complainant. Write narrative reports of survey findings for complaints/incidents investigations, etc. Prepare the statement of deficiencies using Principles of Documentation. Review plans of correction for necessary components, approve or disapprove, and plan and conduct revisit/follow-up activities with providers as needed. Prepare the statement of deficiencies for review by the HCS Supervisor or designee for all surveys conducted. Work as a mentor with new surveyors, such as explaining regulations, participating in on-site survey training opportunities, and comparing draft reports. Develop own survey schedule. - Plan and coordinate preparation for onsite/offsite surveys. - Conduct entrance conference at health care facilities with the senior administrative team to explain survey purpose and process. - Request information required to complete the survey from the facility’s senior administrative team. - Conduct exit conference to facility administrators to inform them of the findings. - Assure complete and accurate survey documents are submitted to the HCS Supervisor or designee. Schedule variations Work requires frequent statewide travel and irregular/flexible work hours including overnights, weekends and holidays in accordance with policy. Public Health Emergency Response This position may be assigned to an emergency assignment to support the public health emergency response mission of the Department of Health. Emergency assignments could at times be received with little or no advance notice, and may continue for any period of time – ranging from a few hours to several weeks, depending upon the nature of the circumstance. The emergency assignments may at times be performed under adverse conditions and may require travel to another site other than the employee’s assigned headquarters for periods of time. Other duties as assigned. Competencies and tasks: Analytical/Assessment Skills - Select and apply valid, reliable data to planning surveys. - Use critical thinking skills to identify gaps in data. - Use available forms and checklists appropriate to the type of facility, survey, and licensure/certification to ensure that surveys are prepared and conducted thoroughly. - Apply working knowledge of regulations, guidelines and definitions to conducting survey, gathering evidence, and writing reports. - Use critical thinking and assessment skills to review and evaluate facility evidence and documentation against regulations. - Unobtrusively observe and document facility operations including care provided to patients/consumers. - Maintain awareness for cues in the surrounding care environment that may lead to additional investigations. - Ensure that all questions receive accurate and complete responses (such as rephrasing questions rather than accepting incomplete or evasive responses). - Prepare concerns and findings using evidence-based conclusions. - Maintain objectivity when observing and gathering information. Communication Skills - Demonstrate customer service skills when interacting with facilities, including over-the-telephone, email, or letter. - Establish rapport, use open-ended questions, and listen effectively when interviewing staff, clinicians, patients/consumers or families. - Defuse elevated communications using paraphrasing, reframing, or validating. - Demonstrate a calm attitude, patience, and listening skills when communicating with a variety of audiences such as patients/consumers, families, colleagues or facility staff. - Refrain from exhibiting bias or judgment when collecting investigatory information. - When conducting onsite investigations, exhibit an assertive, confident attitude and persistence in gathering investigatory information. - Use investigative questioning skills to plan and conduct interviews. - Adjust use of technical jargon to the audience’s level of understanding. - Write reports concisely, emphasizing facts and omitting information not necessary to cite the deficiency by following Principles of Documentation. - Receive constructive criticism positively by listening for opportunities to improve and taking steps to correct behavior or work product. - Prepare reports using legally defensible language at the eighth grade reading level. - Apply discretion, persuasion, and active listening when briefing facility administrators on concerns. - Demonstrate effective presentation skills in conducting meetings with facility administrators. Community Dimensions of Practice Skills - Provide technical assistance and information to family members, patients/consumers or facilities on the survey process and regulations. Cultural Competency Skills - Assess the health literacy of the populations served when evaluating care. - Listen carefully, nonjudgmentally and with cultural sensitivity to patients, families and others to gather survey information from a variety of populations. Professional Skills - Use professional judgment to guide scope and purpose of survey. - Use investigation skills and inquisitiveness to “follow the clues” and bring each potential issue to proper closure. - Nursing Proficiency: As subject matter expert in parenthetical, may provide technical assistance to team members and facility administrators on nursing aspects of surveys, such as wound care or drug interactions. - Nursing Proficiency: Demonstrate culturally appropriate nursing practice. Planning and Management Skills - Organize and plan survey approach prior to onsite/offsite review. - Prioritize workload according to level of importance and schedule changes. - Maintain focus on information necessary to conduct the survey and issue a finding. - Focus communications to gathering survey information and reporting citations while onsite/offsite. - Exhibit flexibility to complete multiple projects simultaneously. - Complete reports during the assigned timeframe. - Maintain flexibility in scheduling Leadership and Systems Thinking Skills - Maintain flexibility in meeting onsite survey requirements and timelines. - Apply confidentiality and privacy guidelines to the use of PHI, patient, or facility specific information. - Maintain updated knowledge of survey protocols, regulations, and guidelines, and apply them in the survey process. Technology Skills - Use federal and state survey systems to gather and document data for surveys. - Use federal/state survey systems to access data. - Use federal/state survey systems to receive and review documentation of potential events. - Use federal/state survey systems to document survey scheduling and log time. - Find regulations online to maintain updated working knowledge. - Access and review patient/consumer electronic clinical records, reports, staffing information and facility policies using facility specific software. - Use technology such as laptops/tablets to record survey evidence, document findings, and draft citations. - Carry and respond to State cell phone as needed. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Leadership role Position represents the Commonwealth and Department of Health when conducting onsite health facility surveys. Decision making in work processes Position is responsible for professional-level decision making, applying standards defined by the supervisor Supervisor’s input in decision making Supervisor reviews all outgoing final correspondence, reports and statements of deficiencies for final approval. Supervisor periodically reviews ongoing work progress and results of assignments. New assignments are performed independently based on knowledge of standards and procedures. Communication Authority Position provides citations of deficiencies and technical assistance on sensitive matters relating to compliance of complex health care regulations. Position conducts entrance interviews, requests survey information from facility administrators, and conducts exit interviews including communicating preliminary deficiencies to facility administrators. Position responds to telephone and hotline calls for consumer/provider questions. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Licenses, registrations, or certifications: 1. Registered Nurse 2. Class C Driver's License 3. N/A 4. 5. 6. |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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