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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 50243156 |
Description Activated On: 2/20/2025 2:51:09 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. The incumbent in this position is responsible to the QA/RM Coordinator. Major responsibilities include knowledge of and the ability to investigate allegations of patient abuse and patient rights grievances for Warren State Hospital. General responsibilities include: knowledge of and the ability to interpret regulatory/accreditation standards; collection and analysis of information and data related to patient abuse and patient rights grievances, hospital practice/procedures, patient trends, and support of the hospital performance improvement plan through conducting investigations, ongoing participation with hospital committees, data collection/distribution to/from department leaders, and data-related inquiries from senior management staff. |
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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. Prepares ongoing and ad hoc data and informational reports for performance monitoring for hospital committees as assigned. Provides education and consultation to hospital staff on issues of study design, statistical analysis, and data needs regarding patient abuse and grievance investigations. Assist with data collection for Risk Management and Utilization Review. Receives allegations of patient abuse and patient rights complaints and analyzes facts to determine the course and scope of the investigation. Identifies the alleged target(s) of the allegation, informing the respective department supervisor in writing for needed action while the investigation occurs. Independently conducts investigations of patient abuse by collecting, evaluating, and preparing evidence, and completing a written report for presentation to leadership, Patient Abuse Committee and external agencies as needed. Gathers information through staff and patient interviews, medical record reviews, video monitoring, and other sources relevant to the investigation, and preserves all evidence. Enters patient abuse information into data base (accurately and up to date) to reflect the most recent information and distributes data timely to appropriate parties. Participates in investigative peer reviews to provide input and ensure standardization of investigation processes. Independently conducts investigations of patient rights grievances by collecting, evaluating, and preparing evidence, and completing the grievance form as required. Ensures the presence of patient grievance forms in all designated/required areas. Completes all forms, reports and documents related to patient abuse investigations and patient rights violations. Testifies and presents evidence as needed at hearings, arbitrations, etc. locally and at state level. Provides guidance and assistance to staff to address and correct allegations of abuse and rights violations; provides written and oral reports on the resolution. Interacts with hospital leadership to determine study performance improvement activities related to CMS, DOH, and other regulatory standards/regulations referencing patient abuse or patient rights. Interacts with hospital leadership and provides data that supports policy changes and development of hospital policies and procedures. Assists hospital leadership in developing indicators and supportive data that can be utilized to measure the effectiveness of treatment of hospital consumers using the principles of recovery and tenets of bio-psychosocial rehabilitation, mental health treatment and systems delivery, as it relates to court/commitment orders and investigations. Develops, facilitates, and studies hospital-wide and department-specific initiatives utilizing the principles and processes of performance improvement, statistical knowledge, and management of information systems. Creates questionnaires, satisfaction surveys, forms, templates, worksheets, workbooks, and relational databases to collect, store, retrieve, analyze, and manipulate data/information for use by leaders in decision-making and performance improvement initiatives. Prepares both oral and written reports/presentations for hospital leaders and committees. Prepares ongoing and ad hoc data and informational reports for performance monitoring for hospital committees as assigned. Collects and prepares reports used to determine impact of clinical care and evaluates optimum care and treatment outcomes for Performance Improvement Activities within the Hospital under the direction of the CPIE which includes assisting with data collection for Risk Management. Responds to requests from CEO, other hospital leadership, department heads, and medical staff for requests and interpretation of hospital clinical and organizational data. Assists with problem resolution in court-related matters, investigations and grievances when requested within the Performance Improvement Department. Contributes suggestions for studies and outcome measurements regarding patient flow, readmissions, discharges, and lengths of stay. Interprets facility, departmental, state and federal policies, regulations and legislation for quality of patient care services for staff and vendor services and provides input for the development of the Hospital's comprehensive quality assurance/risk management plan. Analyzes and evaluates patient/staff incident reports, records of patient care and nutrition needs, medication reports, third party payor reports, administrative policies and practices and practitioner credentials and identifies potential liability problems and issues of noncompliance with regulatory requirements. Participates in house surveys with interdisciplinary clinical and nonclinical administrative and support services staff to identify potential problem areas, recommends methods and actions to prevent and/or to correct staffing and/or operating deficiencies, and monitors follow-up activity reports to ensure timely and appropriate actions are taken to minimize and/or to prevent problem reoccurrences. Accomplishes and coordinates quality assurance/risk management monitoring and evaluation studies with Medical Records and Utilization Review Staff, clinical interdisciplinary staff or others to identify patterns and trends of care and treatment planning, monitors and evaluates treatment activities leading to successful placement in the community; and monitors and evaluates readmission information for use in recommending changes in treatment planning. Participates in the organization and coordination of independent third party surveys conducted by certifying and accrediting agencies for compliance with state and federal regulations and legislation and DHS standards by completing required pre-survey forms and assembling documentation and records for review by surveyors, and accompanying them on the on-site review. Provides input to and assists in the implementation and monitoring of action plans to minimize liability problems and to correct deficiencies identified by independent survey teams. Prepares reports and maintains files and records of performance improvement/risk management monitoring and evaluation activities and completed studies. Serves as facilitator for Community Support Plan meetings as needed. Obtain and maintain current crisis response/interventions training and appropriately use and apply these skills. Completes other related duties/tasks as assigned. |
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. 1. Determines what types of information/data is both available and needed within the organization and how such information/data can be developed to meet various needs of hospital leaders to assure Patient Rights are protected. 2. Determines the best way to capture, analyze and present information/data. 3. Develops indicators and supportive data that can be used by hospital leaders in their decision-making. 4. Determines the best format and approach to gather, analyze, and present information. 5. Understands and assures confidentiality regarding sharing information regarding patients and staff. |
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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. N/A 2. N/A 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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