Nature of Work
Under general supervision, performs advanced level professional work conducting complex regulatory compliance determinations during inspections of health care facilities including, but not limited to: hospitals, long term care facilities, home health agencies, hospices, residential board and care facilities, personal care homes, ambulatory surgery centers, end stage renal dialysis units, rural health clinics, screening mammography facilities and clinical laboratories. Functioning as team leader of a disciplinary team, surveys facilities through observation of care and delivery of services, interviews and review of documentation such as policy and procedures, committee meeting minutes, facility operating records, personnel files, training records and patient/resident medical records. Work involves frequent overnight travel (up to 90%). There is considerable dependence on professional judgement in the performance of a survey. The purpose of a survey is to determine compliance of providers/suppliers and State and federal requirements for licensure and/or Medicare/Medicaid certification, and, on occasion, to provide technical assistance to facilities regarding compliance standards and development and implementation of procedures to improve client/patient services. Functions as a lead worker. Performs related work as required.

Distinguishing Characteristics
This is the advanced level in the series. An employee in this classification would be expected to act as a team leader of a multi-disciplinary survey team and/or as a lead worker on a regular, recurring basis.

Examples of Work
As team leader of a survey team, discusses areas of non-compliance with team members, compiles recommendations concerning licensure and/or certification status, edits final reports and reviews corrective measures.
Participates in developing, reviewing and revising health care regulations based on changes in state or federal regulations or studies, submits drafts of proposed changes to various organizations and agencies for comment and discussion.
Conducts on-site survey of behavioral and medical health care facilities; discusses survey procedures and practices with administrators and department directors.
Observes client/patient care, collects and records objective data, reviews medical and other records, interviews clients/patients in a group or individually, evaluates policy and treatment or therapeutic services to determine accuracy and adequacy of program/service delivery.
Reviews facility operative and management records, committee meeting minutes and related records as well as resident personal funds accounts to determine compliance with regulatory requirements.
Reviews organizational charts, personnel credentials and training records, and policies and procedures to determine appropriate staffing levels and qualifications of staff to perform services.
Tours the facility to evaluate physical environment compliance of areas such as laboratory, patient treatment and living areas, kitchen and pharmacy.
Evaluates social services, activities, recreation and resident rights issues to ensure provision of services and quality of life.
Utilizes laptop computer system to compile, document and record data and to print preliminary findings.
Meets with other survey team members to research facility history, review appropriate regulations and to delegate survey duties for each survey, reviews accommodation and travel plans, submits detailed expense and activity reports.

Knowledge, Skills and Abilities
Knowledge of technical health and safety related fields including special education, behavioral health and laboratory services.
Knowledge of medical and behavioral terminology, health care organizations, professional credentialing and practice standards and treatment modalities as they relate to one or more of the following: medical, nursing, social, laboratory medicine or science, behavioral health, dietary, pharmaceutical, therapy services and documentation principles related to each.
Knowledge of practices and procedures in medical care administration and health services provision.
Ability to comprehend, interpret and apply complex information and program material.
Ability to work well with a variety of people.
Ability to communicate well, both orally and in writing.
Ability to exercise good judgment in evaluating situations.
Ability to manage time effectively.
Ability to lead co-workers.

Minimum Qualifications       [Top]
Training:
Graduation from an accredited four-year college or university with a major in nursing, social work, vocational rehabilitation, hospital or health care administration, nutrition, psychology, counseling, medical records management, clinical laboratory or related sciences, recreation, speech, physical or occupational therapies or other related health/social services/educational fields or safety, engineering or architectural design. If employed in the Long Term Care Program of the Office of Health Facility Licensure and Certification, must have successfully completed the Surveyors and Minimum Qualifications Test (SMQT), excluding Life Safety Code surveyors.
Substitution:
Experience as described below will substitute for the required training on a year for-year basis.

Experience:
Four years of full-time or equivalent part-time paid professional experience in public health, social work, nursing, vocational rehabilitation, hospital administration or related health program, safety, engineering or architectural design, OR four years of full time or equivalent part-time paid experience as a building maintenance supervisor.
Substitution:
A Master's degree in one of the above subject areas may substitute for one year of the required experience.

Note: If employed in the Nursing Home Program of the Office of Health Facility Licensure and Certification, must have a current WV Nursing Home Administrator's license in good standing, excluding life safety code surveyors and licensed or registered dieticians.

Established: 12/19/96
Revised:      1/06/98, 3/2/04, 3/18/05, 8/08/06
Effective:     8/08/06

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