Overview

POSITION SUMMARY:

Provides Survey management in a regional setting according to policies and procedures, and federal/state requirements. Responsibilities include attendance and participation during facility self-assessment phases and providing evidence-based knowledge to the field for each discipline for successful survey compliance and outcomes. The SIM works effectively with clients and all HCSG disciplines to ensure that regulatory compliance is understood and being met. Consistently embodies the characteristics necessary to drive the Company’s Purpose, Vision, Values, and DNA. Although this is not a supervisory function, the SIM has the authority to train employees as to proper techniques, etc. as they see fit.

SIM will report to the Senior Director of Operations/ Senior Director of Clinical operations as applicable. Travel required greater than 75% of the time.

ESSENTIAL FUNCTIONS OF THE JOB:

• Provides survey assessment and management in centers, sometimes multiple centers simultaneously, in accordance with a predetermined schedule as identified by the Senior Director of Operations/ Senior Director of Clinical Operations.

• Accurately interprets department policies and procedures and articulates impact to employees, residents, visitors, government agencies, etc., as necessary.

• Attends Mock surveys and completes audits according to CMS regulations and Critical Element Pathways. Including completing the following in their entirety:

• Nutrition Critical Element Pathway

• Kitchen Observation Critical Element Pathway

• Kitchen Sanitation Critical Element Pathway

• Dining Room Observation Critical Element Pathway.

• Interview facility staff/residents/family members about Dining Services (this may be included in critical element pathway)

• Environmental services pathways as applicable

• Coordinates with Clients Mock Survey Team to coordinate HCSG EVS, Dining and Clinical Attendance at each Mock Survey.

• Develops a 2567-like report with detailed findings during Mock survey

• Reviews and presents findings from all mock surveys to field teams and work collaboratively (DO, DCO, Lead RD, District Manager, RD, AM) so that team members can develop a POC for findings within one week of survey report.

• Note: All I/J / G level care concerns identified should be addressed on the spot with additional follow up post review.

• Utilize the POC Template to correct the issues:

• What was the problem identified

• Immediate corrective action

• Process Improvement put into place

• What follow up and monitoring will be done and who is responsible for this on an ongoing basis

• Follows the Survey HEAT map in conjunction with client mock survey schedule to determine pre-survey review needs.

• Analyzes past survey results (tag number, scope/severity, description of non-compliant practice) and provides this information to HCSG team members, for preparation of CMS survey to decrease potential for repeat tags.

• Reviews and analyzes Monthly Sanitation Audits and tour reports to trend most recent results

• Tracks and Trends CMS Annual survey results:

• Assists the local teams with POC completion and follow up for CMS Surveys

• Works closely with client on special focus facilities, including coordinating additional facility support visits with operations and clinical teams as applicable.

• Works closely with HCSG Senior Ops and Clinical leadership as well as Client RVPs, and VPs of Clinical on any additional follow up needs.

• Reviews the health of Mealtracker remotely. In addition to Critical element pathways the following items must be completed/ reviewed:

• Using the correct menu – imported correctly

• Resident information entered correctly

• Resident preference entered correctly

• Review of Supplement usage

• Review of snack labels

• Be a resource to HCSG field team during survey

• Policies and procedure retrieval or questions

• Mealtracker questions

• Retrieval of clinical documentation if additional support is needed.

• EMR support

• Involvement in Quarterly client QBR process

• Identifies additional training /education opportunities as it relates to survey competency and compliance. Conduct trainings as needed.

• Reviews and makes recommendations for an ongoing quality assurance program for the HCSG Services Departments.

• Participates in facility/state federal inspections as directed.

• Provides consultation to both client and HCSG management on federal, state, and local regulations pertaining to dining service operations.

• Participates in HCSG district and/or regional meetings as required.

• Recommends to the Director of Dining Services the equipment and supply needs of the department and assists with placing orders, as needed.

• Makes periodic rounds to inspect equipment, supply rooms and custodial closets and to ensure that necessary supplies and equipment are available and working properly.

• Evaluates inventory levels of food and supplies to be sure that an adequate stock of staple/non-staple food, supplies, equipment, etc., is maintained according to state guidelines.

• Assists in the purchase of food, supplies, equipment, etc., as needed.

• Performs all other duties as assigned.

  QUALIFICATIONS:

• Certified Dietary Manager, Diet Technician, or Registered Dietitian credential required

• Demonstrated experience and expertise in CMS survey excellence required

• Demonstrated experience in multi-unit management required

• In-depth knowledge of the senior care industry, including dietary services and/or environmental services required

• In-depth knowledge of state and federal nursing home regulations in the areas of food & nutrition services and/or environmental services, including safety/sanitation required

• Must have the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies, procedures, etc., of clinical, dining and EVS Departments.

• Must be able to read and interpret regulations, policies and procedures.

• Highly effective collaborator with internal and client resources

• Results oriented with ownership of goals and objectives

• Ability to identify and highlight issues early on and quickly develop and execute correctional measures

• Ability to exercise independent judgment

• Excellent oral/verbal and written communication skills

• Greater than 75% travel (as necessary) is required for account/facility visits and client interaction

• Must submit to a criminal background check

  HCSG is proud to be an equal opportunity employer committed to all employees and applicants for employment regardless of race, color, religion, sex, national origin, age, disability, genetics, ethnicity, pregnancy status, gender identity, sexual orientation, marital status, political opinions, or affiliations, veteran status, or other legally protected classes. HCSG also complies with applicable state and local laws and federal law requirements that govern nondiscrimination in every location where we operate.

  HCSG is committed to fostering and supporting a vibrant company culture that encourages employees to bring their authentic and best selves to serve our resident and client communities. We believe all employees, regardless of position, age, race, religion, beliefs, socioeconomic background, or gender, should work in an environment where they are safe, respected, and treated fairly, with their viewpoints, thoughts, and ideas encouraged and embraced.

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Job LocationsUS-KY-LOUISVILLE | US-KY-LEXINGTON

Updated Date9/20/2024

Requisition ID2024-615630

ShiftFlexible

TypeFull & Part-Time

Location : Postal Code40216-4701

Division : NameDivisionL