|
Commonwealth of Pennsylvania |
|
|
POSITION DESCRIPTION FOR JOB POSTING |
|
|
Position Number: 00252101 |
Description Activated On: 9/23/2025 7:40:46 AM |
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 Nursing Care Facilities (NCF) supports the Department’s mission of protecting the public health through its responsibility for conducting health care surveys in nursing care facilities to determine compliance with federal and state regulations. |
|
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: Use information and data available for specific facility to prepare and plan for surveys or independent reviews. Conduct surveys, which may include survey types such as complaints, incidents, full/annual health surveys, abuse investigations, in-office or on-site revisit surveys, civil rights surveys, special CMS surveys, and occupancy surveys using federal and state regulations for initial licensure, re-licensure, civil rights, and/or Medicare/ Medicaid certification to determine compliance. Review reports of incidents (via Events Reporting System) as assigned and communicate with providers electronically or verbally for follow-up and/or additional information as needed. May also include review of PB-22 forms and answering the complaint hotline as assigned and communicating with complainants. Review reported events, prioritizing follow-up according to level of urgency, including reporting serious events and events that contain potential non-compliance to the supervisor, and initiating onsite investigation when necessary. Write reports of survey findings using Principles of Documentation in state or federal systems. 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 Health Care Surveyor Supervisor or designee. Function as independent surveyor, as team member, or as team leader as assigned. Assist and coach new surveyors, explain regulations, provide preparation and on-site survey training opportunities, review draft reports and deficiencies/findings, and contribute to evaluating the performance of new surveyors, as assigned. When assigned team leader role for surveys: - Plan and coordinate preparation for on-site surveys. - Determine team composition based on records review and facility type. - Coordinate and assign survey tasks to team members equitably. - Conduct team preparation meeting prior to survey. - 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. - Coordinate and conduct team meetings and conferences at the site to coordinate survey findings and formulate deficiency statements. - Conduct exit conference to facility administrators to inform them of the findings. - Assure complete and accurate survey documents are submitted to the Health Care Surveyor Supervisor or designee. Other duties as assigned. Schedule variations Work requires frequent statewide travel and irregular/flexible work hours including overnights, weekends and holidays in accordance with policy. Employee may travel using public transportation, private transportation or carpooling with other team members as assigned. 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. 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 residents. - 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, residents 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 residents, families, colleagues or facility staff. - Refrain from exhibiting bias or judgment when collecting investigatory information. - When conducting on-site investigations as an independent surveyor, 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. - 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. - Participate as a team member on surveys, using one another’s strengths and expertise to formulate deficiencies. - As team leader, apply discretion, persuasion, and active listening when briefing facility administrators on concerns. - As team leader, demonstrate effective presentation skills in leading team meetings and conducting meetings with facility administrators. Community Dimensions of Practice Skills - Provide technical assistance and information to family members, residents or facilities on survey policies 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. • 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. 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 information on nursing aspects of surveys. - Nursing Proficiency: Demonstrate culturally appropriate nursing practice. Planning and Management Skills - Organize and plan survey approach prior to on-site review. - Function as an independent surveyor, as a team member, or as a team leader. - 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 with colleagues to gathering survey information and reporting citations while on site. - Provide regular updates to team leader and members. - Exhibit flexibility to complete multiple projects simultaneously. - As team leader, demonstrate fairness in developing and conducting survey plan, considering the plan’s potential impact on survey process, survey team, and facility. - Complete reports during the assigned timeframe. - As a team member, maintain flexibility in scheduling or carpooling. Leadership and Systems Thinking Skills - Maintain flexibility in meeting on-site survey requirements and timelines. - Apply confidentiality and privacy guidelines to the use of PHI, patient, resident 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. - Toggle between Word and federal and state survey systems - Use federal survey systems to access data. - Use state survey systems to receive and review documentation of potential events. - Use state survey systems to document survey scheduling and log time. - Find regulations online to maintain updated working knowledge. - Access and review resident 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. |
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 may work as a team member or team leader. Decision making in work processes Position is responsible for professional-level decision making, applying standards defined by the supervisor and the proper technical discipline. Supervisor’s input in decision making Supervisor reviews all outgoing correspondence and documents. Supervisor periodically reviews ongoing work progress and results of some assignments. New assignments are performed independently based on knowledge of standards and procedures. Communication Authority Position may act as an independent representative of the Commonwealth and Department of Health when conducting onsite health facility surveys. Position provides citations of deficiencies and technical assistance on sensitive matters relating to compliance of complex health care regulations. As team leader, position conducts entrance interviews, requests survey information from facility administrators, and conducts exit interviews including communicating citations and deficiencies to facility administrators. |
||||||||||||||||||||
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. N/A 5. N/A 6. N/A |
||||||||||||||||||||
Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
|