Survey Readiness Manager - Healthcare Services Group, Inc.

TITLE: Survey Readiness Manager (SRM)
DEPARTMENT: Dining Operations
REPORTS TO: Director of Survey Readiness
STATUS: Exempt (salaried)
EMPLOYMENT: Full-Time

Provides Survey management in a client-centric or Divisional setting according to HCSG
policies and procedures, and federal/state requirements. Responsibilities include attendance
and participation during facility self-assessments (mock surveys) based on CMS regulations.
Mock surveys are to be conducted for facilities in survey window as well as by client-request.
This position will communicate findings to HCSG operational leadership and work through a
plan of correction (POC). The SRM works effectively with clients and all HCSG disciplines to
ensure relationship connectivity and to ensure that staff understand and meet policies,
procedures, and state and federal regulations. This position consistently embodies the
characteristics necessary to drive the Company’s Purpose, Vision, Values, and DNA. Although
this is not a supervisory function, the SRM has the authority to train employees as to proper
techniques, etc. as dictated by HCSG policies and procedures and CMS guidelines.
SRM will report to the Director of Survey Readiness. Travel required greater than 75% of the
time.

Responsibilities:

• Utilizes and follows the survey HEAT map in conjunction with client mock survey
  schedule to determine timing of pre-survey review visits.
• Conduct mock surveys according to CMS regulations for facilities in window as well as
  facilities identified through use of internal data.
• Develop a prioritized schedule based on the points mentioned above, keeping in
  mind that Operations may dictate a visit to review another facility or make
  adjustments to the schedule.
• Accurately interprets HCSG policies and procedures and articulates the impact
  proper execution has on employees, residents, visitors, government agencies, etc.,
  as necessary.
• Attends client-scheduled mock surveys and completes audits according to CMS Regulations,
  including completing the following Critical Element Pathways:
  • Kitchen/Food Service Observation
  • Dining Observation
• Coordinates with Client’s Mock Survey Team and HCSG Dining and Clinical to ensure
  attendance at each mock survey.
• Provides a detailed summary of findings during/following mock surveys.
• Reviews and presents findings from all mock surveys to field teams and works collaboratively (DO, DCO, Lead RD, District Manager, RD, AM) so that team members can develop and implement a POC within a reasonable time frame given survey window status.
• 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 issues:
• What was the problem identified
• Ensure immediate corrective action is taken
• Ensure process improvement plan is put into place detailing follow up and monitoring what will be done and who is responsible for this on an ongoing basis.
• To decrease the potential for repeat tags, analyzes past survey results (tag number,scope/severity, and description of non-compliant practice) and provides this information to HCSG team members, in preparation for a state/federal survey.
• Reviews and analyzes Monthly Sanitation Audits, Quality Assurance Evaluation(QAE), and other tour reports (e.g. test trays, satisfaction surveys) to trend most recent results.
• Reviews, tracks and trends CMS annual survey results:
  • SRM works with Corporate Training, Dining, Survey Excellence, and local teams to assist with POC completion and follow up for CMS surveys
• Works closely with client on Special Focus Facilities (SFF), including coordinating additional facility support visits with operations and clinical teams as applicable.
• Works closely with HCSG Ops and Clinical leadership to address Client RVPs, and VPs of Clinical on any additional follow up needs.
• Along with the appropriate level(s) of facility and operational/clinical management, reviews, communicates, and ensures follow-up to maintain the health of Mealtracker remotely. The following items must be 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 mock or pre-survey activities.
• Works with Client Services Manager to determine involvement in Quarterly client QBR.
• Consults with the Training Team to identify training /education opportunities as it relates to pre-survey competency and compliance. Conducts supplemental live trainings as needed. Reviews and makes recommendations for ongoing quality assurance projects for the HCSG Food and Nutrition Services Department.
• Works with HCSG Policy and Training Development Department to ensure client and HCSG management understanding of local, state, and federal regulations pertaining to food and nutrition service operations.
• Participates in HCSG district and/or regional meetings as requested.
• Makes recommendations to the Account Managers, District Managers, and Directors of Operation for the equipment and supply needs of the department identified during a mock survey.
• Performs all other duties as assigned.

Qualifications: 

• Proven successful operational experience with in-depth knowledge of long-term care,  including food and nutrition services required
• Certified Dietary Manager (CDM), Food Service Manager (FSM) and Long-Term Care  Food Service (LTC-FSM) certification, Diet Technician, or Registered Dietitian credential  highly preferred
• Demonstrated knowledge, experience, and expertise in the application of CMS regulations  and the most up-to-date Food Code required
• Demonstrated experience in multi-unit management required
• In-depth knowledge of state and federal nursing home regulations in the areas of food  and nutrition services including safety/sanitation required.
• Must have the ability to understand the HCSG defined programs, goals, objectives,  policies, procedures, etc., of the Food and Nutrition Services Department. ∙
• Must collaborate with the Policy and Training Development Department when interpreting regulations, policies and procedures.
• Highly effective collaborator and communicator with internal and client resources ∙ Results oriented with ownership of pre-survey goals and objectives
• Ability to identify and highlight pre-survey issues early on and quickly work with subject  matter experts to 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 be fluent in English - reading, writing and speaking
• Must submit to a criminal background check

Knowledge, Skills & Abilities: 

• Professional Licenses: Certified Dietary Manager, Diet Technician, or Registered Dietitian  credential highly preferred

• Other Licenses: Valid driver’s license

• Computer software (please specify): Intermediate or above computer skills, including business related software (Email, Food Service Management Technology programs- Mealtracker, DSSI,  MS Office, Google Suite, etc.) with the ability to become proficient within first 3 months of  introduction of any computer and computer software provided to improve recordkeeping and efficiency

• Machine operation (please specify): Copier, fax, calculator, computer, and other  office equipment; as well as all standard kitchen equipment.

HCSG is proud to be an equal opportunity employer committed to all employees and applicants 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.

Our Commitment to Diversity and Inclusion

We are 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.