Health Facilities Certification and Licensing — Our office is responsible to license and certify health facilities throughout the state of Alaska.
The Health Facilities Surveyors supervise and perform inspections of health care facilities to assess compliance with State licensure and/or Medicare/Medicaid certification standards.
Health Facilities Surveyors I perform professional on-site inspections and reviews of health care facilities. As a member of a survey team, incumbents apply professional knowledge and expertise in a specialty area, such as nursing, medical technology, dietetics, sanitation, social work, or health administration, to analyze and assess the activities in the facility. Inspections cover all areas in a facility such as medical staff by-laws; surgical, obstetrical, emergency, pharmaceutical and rehabilitation services; nursing services; infection control practices and surveillance methodology; administrative services including personnel, financial and clinical records; physical plant structures; dietary, housekeeping, and laundry services; and risk management. Incumbents survey a variety of facilities including hospitals, nursing homes, home health agencies, rural health clinics, birthing centers, ambulatory surgery centers, independent laboratories, outpatient physical therapy services, and so on. Incumbents may lead a survey team when certified for the specific type of facility.
The primary skills and duties of a Health Facility Surveyor include, but are not limited to the following:
- Participates and exercises professional judgment as member of interdisciplinary teams to assess health facilities' services;
- Conducts evaluative surveys for the purpose of determining the degree and level of compliance with State licensure regulations for general acute care hospitals, rural primary care hospitals, nursing homes, assisted living homes, birthing centers, substance abuse facilities, psychiatric hospitals, rehabilitation hospitals, hospice agencies, home health agencies, and ambulatory surgical centers;
- Conducts evaluative surveys for the Medicare and Medicaid certification in accordance with participation requirements as adopted by the Secretary of Health and Human Services, and program directives issued by the Social Security Administration and Centers for Medicare and Medicaid Services (CMS);
- Prepares, under strict deadlines, accurate and comprehensive survey reports (Statements of Deficiencies) with supporting documents and data reflecting facility operation and compliance with standards;
- Applies clinical nursing skills in assessing services to meet patient needs. Must have and be able to apply a broad understanding of the needs of the elderly, mentally ill, and the disabled;
- Demonstrates a thorough knowledge of nursing principles, practices, and objectives. Effectively provides training under informal and spontaneous conditions in a manner to inspire instead of coerce;
- The surveyor will assimilate large amounts of highly technical and diverse medical information and interprets that information at many levels. Flexibility to adjust to complex changes in regulations and interpretations is a plus;
- Studies, interprets and is considered a resource person in all phases of governing regulations and guidelines as they apply to licensure or certification;
- Conducts necessary follow-up surveys within specific time frames mandated by Medicare/Medicaid regulations. These follow-up reviews also apply to State licensure of hospitals and nursing homes. Prepares appropriate federal/state documentation in assessing the quality and status of the facility's efforts to correct deficiencies;
- Coordinates intakes and conducts investigations of complaints in accordance with established protocols, making regulatory compliance determinations in relation to allegations received. Complaint investigations may be conducted independently or as part of a team;
- Participates in the development or revision of State regulations and status, as necessary, to ensure safe and quality health care delivery by licensed facilities;
- On an ongoing basis, the surveyor will be required to communicate with organizations or persons inside and outside State government;
- Participates in Federally required training programs;
- Prepares non-survey related correspondence and communication with providers, consumers, public, media, and other State and Federal agencies;
- Participates in internal training and in-service programs;
- Participates in the Quality Improvement Program, including projects that may be coordinated with the provider organizations, designed to improve the quality of care and quality of life for health care consumers;
- Participates as a training/consultant/resource person in pertinent educational programs for professional and/or laypersons employed in licensed and certified health care facilities. This may involve speaking at State conventions when requested.
