View complete job posting at
https://jobs.hrd.state.ma.us/recruit/public/31100001/job/job_view.do?postingId=J41100&code=search.public&federalStimulus=no&companyId=61
Duties:
Responsible for supervision of assigned staff and managing all assigned complaint and annual state licensure and federal Medicare/Medicaid certification inspections for all health care program and facility types in the assigned geographical region e.g., hospitals, home health agencies, hospice agencies, skilled nursing facilities, rest homes, ambulatory surgical centers, end stage renal disease centers, clinics etc.. This includes hiring staff and evaluating staff performance via the employee performance review system; planning survey schedule and reviewing survey findings. Provide expert guidance, consultation, information and training to staff, consumers and at provider conferences and workshops.
Make final clinical assessments and determination to the accuracy of survey findings and whether deficient practice exists. Present cases which have been appealed to the Informal Dispute Review board. Implement quality assurance and performance improvement program for the assigned region to ensure quality, timeliness and consistency of work. Work on special survey related projects. Work as part of a management team to accomplish all required inspection activity statewide. Attend required management meetings. Represent the Department at assigned professional workgroups.
Detailed Statement of Duties and Responsibilities:
1. Review and evaluate final survey documentation to ensure compliance with federal and state policies and procedures; and, sufficient clinical and legal evidence to support findings. Sign off on all legal statement of deficiencies being issued to providers.
2. Coordinates for the timely completion of survey and assigned complaints in accordance with established priorities, the timeframes established by state and federal regulations, and the Department’s policies. Supervises assigned surveyors to ensure they perform their duties in accordance with the survey protocols and guidelines, applicable personnel and work policies.
3. Analyze and review results of the survey process to determine future survey activity.
4. Assure providers not in compliance with regulations are brought to the attention of the Compliance Unit. Manage on-going inspections of providers needing to be monitored.
5. Plan the monthly and annual survey schedules for all assigned provider types e.g., long term care, home health agency, hospice, clinic programs, etc.
6. Plan and conduct various meetings such as staff monthly and training meetings and attend supervisor and other meetings as needed.
7. Manage the daily operations of the region. (e.g., scheduling of work, responding to staff, providers, consumers, enforcement issues, inter/intra agency issues, etc.).
8. Conduct six month personnel performance evaluations and annual reviews.
9. Assure accurate interpretation by staff of certification and licensure requirements.
10. Conduct on-site visits with staff at health care facilities as needed.
11. Collect compile and analyze data regarding survey activity. Shares findings with peers, supervisors and subordinates to ensure unit priorities and goals are achieved. Uses data to develop short and long range goals for review and investigation.
12. Develop a regional QAPI program to ensure consistency in work product; efficiency in work production and effectiveness in survey activity.
13. Prepare monthly and quarterly regional data.
14. Communicates in a clear, timely, effective and supportive manner with subordinates, peers, supervisors, outside agencies, providers and the public. Notifies appropriate people of significant issues in a timely manner. Ensures that all communications of the unit are consistent with privacy requirements applicable to private health information and other personal information.
15. Oversee the development of forms, procedures and documents related to new and current regulatory initiatives.
16. Represent the Division on various state and provider association committees to promote Division goals.
17. Collaborates with providers, ombudsman program, attorney general’s office, centers for Medicare and Medicaid and other relevant state and federal agencies as needed.
Qualifications:
MINIMUM ENTRANCE REQUIREMENTS:
Applicants must have (A) at least three years of full-time, or equivalent part-time, experience as a registered nurse in a recognized hospital, clinic or medical facility, and (B) of which at least one year must have been in a supervisory, administrative, or managerial capacity and (C) three years of full-time, or equivalent part-time experience as an inspector of health care facilities/services or (D) any equivalent combination of the required experience and the substitutions below.
Substitutions:
I. A Bachelor's degree with a major in nursing may be substituted for a maximum of one year of the required (A) experience.*
II. A Graduate degree with a major in nursing may be substituted for a maximum of two years of the required (A) experience.*
*Education toward such a degree will be prorated on the basis of the proportion of the requirements actually completed.
NOTE: No substitutions will be permitted for the required (B) or (C) experience.