Survey Readiness Manager

Additional Information

This position will support operations across the West Virginia market.

Overview

TITLE: Survey Readiness Manager (SRM)DEPARTMENT: Dining OperationsREPORTS TO: Director of Survey ReadinessSTATUS: Exempt (salaried)EMPLOYMENT: Full-Time

Benefits Link

Click here for more benefits information

 

or copy this link: https://go-internal.hcsgcorp.com/l/1036773/2025-07-02/5xbpsq/1036773/17514637576MrQym5A/Employee_Benefits_for_Job_Descriptions__7_.pdf

 

*Not available in AR.

Responsibilities

Provides Survey management in a client-centric or Divisional setting according to HCSGpolicies and procedures, and federal/state requirements. Responsibilities include attendanceand 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 aplan of correction (POC). The SRM works effectively with clients and all HCSG disciplines toensure relationship connectivity and to ensure that staff understand and meet policies,procedures, and state and federal regulations. This position consistently embodies thecharacteristics necessary to drive the Company’s Purpose, Vision, Values, and DNA. Althoughthis is not a supervisory function, the SRM has the authority to train employees as to propertechniques, 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 thetime.

 

Responsibilities:

• Utilizes and follows the survey HEAT map in conjunction with client mock surveyschedule to determine timing of pre-survey review visits.
• Conduct mock surveys according to CMS regulations for facilities in window as well asfacilities identified through use of internal data.
• Develop a prioritized schedule based on the points mentioned above, keeping inmind that Operations may dictate a visit to review another facility or makeadjustments to the schedule.
• Accurately interprets HCSG policies and procedures and articulates the impactproper 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 ensureattendance 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 en