Occurrence Reporter - HEALTH PROFESSIONAL III - Pueblo
Occurrence Reporter - HEALTH PROFESSIONAL III - Pueblo
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$ 63456 - 88860
1 Vacancy
Job Description
Department Information
- This position is open only to Colorado state residents.Opt in below to receive text message updates on CDHS recruiting events!
CDHSCareers Description of Job
Job Assignment
The Quality Management Department (QM) exists to provide guidance to the Colorado Mental Health Hospital in Pueblos efforts to meet or exceed customer expectations by maintaining excellence in patient care and to identify opportunities for improvement through analysis interpretation and dissemination of databased information that enables hospital leadership to utilize resources in an efficient manner and to operate effectively under legislative mandates and administrative policies.
This position exists to assist with the implementation of the CMHHIP Critical Incident Reporting Program as outlined in CRS 253109. This position reviews and analyzes incident reports using the standards of practice set by the Colorado Department of Public Health and Environment (CDPHE) and provides follow up for Colorado Mental Health Institute at Pueblo (CMHHIP) Office of Behavioral Health (OBH) and Colorado Department of Human Services (CDHS). Investigates and determines which events constitute a critical incident/occurrence and determines which of those must be reported to Executive Management in Denver CMHHIP leadership including the hospital CEO and the Deputy Director of Clinical Services for OBH and Colorado Department of Public Health and Environment (CDPHE). Collaborates with Program/Unit Leadership Department of Public Safety (DPS) and appropriate Department Heads to respond to and investigate serious allegations that may require immediate response of an appointing authority to determine appropriate action to keep patients safe at all times.
Participates in root cause analysis investigations to direct formulation of quality improvement strategies. Managers and peers internally and externally to CMHHIP rely on this pacesetter when making decisions regarding course of action policy revisions or programmatic changes that would be appropriate to maintain optimum patient safety and ongoing treatment. Generates a weekly report from the database which is disseminated to hospital leadership and appropriate OBH Leadership. Recommends updates to policy and procedure and sits on policy committees.
Maintains updated knowledge of standards: 2765 Statute CMS JCAHO and Health Department. Assists in all onsite survey activities (accompanying surveyors throughout the hospital) and/or provides assistance to the Director of QM with completion of the Joint Commissions Focused Standards Assessment (FSA) which is submitted to TJC in nonsurvey years. ADHOC Reference Committee member for the Policy and Procedure process that is utilized for ongoing policy and procedure updates which is based in QM.
Job Duties:
Critical Incident/ Occurrence Investigation and Reporting:- Ongoing development and implementation of the CMHHIP Critical Incident Reporting Program as outlined in CRS 253109.
- Collects analyzes and reports data related to hospitalwide incidents in order to improve patient and staff safety.
- After investigating the incident and assessing the data collected determines which events constitute an occurrence that must be reported through the iNotify database to Executive Management in Denver CMHHIP/OBH leadership including the hospital CEO and the Deputy Director of Clinical Services for OBH.
- Investigates and conducts mini root cause analyses into the incidents to further determine which incidents rise to the level of required reporting to the Colorado Department of Public Health and Environment (CDPHE) or the Joint Commission (TJC) as a Sentinel Event.
- Investigates and develops followup reports on any occurrence that meets the criteria which includes but is not limited to visual review of video footage performing interviews alone with staff and patients recording interviews listening to recordings searching areas of the hospital entering patient care areas and reviewing documentation.
- Additionally this position is involved in the completion of Apparent Cause Analysis and Root Cause Analysis for critical incidents investigations.
- This position is required to complete emergency physical intervention/restraint training (CTI) and CPR.
- Collaborates with and advises Program and Unit Leadership Department of Public Safety and Department Heads to respond to and investigate serious allegations that may require immediate response of an appointing authority to determine and develop an appropriate action to keep patients safe at all times.
- Formulates recommendations for change or improvement in operating procedures.
- Completes audits under the direction and in collaboration with the Quality Management QAPI team.
- Collects and summarizes findings by aggregating data per regulatory guidelines.
- Reports findings to the Director of Quality Management and QAPI Supervisor.
- Assists with completing data input and collaborates on system maintenance for Quality Management spreadsheets and databases for audits focused audits or focused audits Requested by legitimate special interest entities affiliated with CMHHIP and TJC Tracers.
- Assists in determining the best method of data presentation based on the intended audience.
- Uses an established database in which results of all audits are maintained and through which comprehensive reports (including graphs and charts) may be extracted for the Director of Quality Management Executive Committee or Program and Department Heads.
- Maintains a system for tracking chart delinquencies with a goal of no delinquencies older than 30 days hospitalwide.
- Monitors delinquencies and works with clinical staff to correct them within established timelines.
- Coordinates resolution of delinquencies with Quality Management QAPI team.
- Provides reports on delinquencies to the Director of Quality Management and Quality Management QAPI supervisor.
- As part of the utilization management program this position may be asked to participate in various aspects of utilization review.
- For example compose clinical letters in reply to thirdparty payer denial for reimbursement and auditing the medical record to determine if there is additional documentation to be included to support medical necessity.
- Under direction of the Quality Management Director provides backup support in the Tracer process which mimics the tracer methodology employed by the Joint Commission when they conduct onsite surveys for themselves and CMS.
- Uses knowledge of Joint Commission and CMS Standards to complete intense observation of all areas to include patient care areas assessing environment of care patientstaff interactions observation of medication administration seclusion and restraint programming plan of care reviews etc.
- It also involves detailed audits of medical records on each unit visited to ascertain compliance with Joint Commission/CMS Standards.
- Tracers also review ancillary services such as Radiology Clinics and Physical Therapy etc.
- This position specifically reviews Ambulatory Care Services Physical Therapy Dental Services and Radiology.
- Responsibility to perform assigned tasks and duties within the scope of practice for this position that do not fall within the realm of duty statements AC to meet the vision and mission of the agency and/or the department.
Minimum Qualifications Substitutions Conditions of Employment & Appeal Rights
- Minimum Requirements:Experience Only:Acceptable degree plans include: Clinical Nursing Psychology Social Work etc.
Six (6) years of relevant experience in an occupation related to the work assigned to this position.Relevant experience in a clinical or hospital setting and/or Behavioral Health experience
OR
Education and Experience:
A combination of related education and/or relevant experience in an occupation related to the work assigned equal to six (6) years.
Note: Please be sure to indicate related experience in each job experience listed as these will determine calculations of related experience.
Preferred Qualifications:- Demonstrated computer proficiency
- Well developed interpersonal skill: ability to remain professional in stressful situations
- Attention to detail
- Well developed and demonstrated writing skills
- Bachelors degree or higher in the clinical field of Counseling Psychology Nursing or Social Work.
- Five or more (5) years of experience working in a clinical or hospital setting.
- Behavioral health experience
- Experience investigating occurrences
- Prior utilization management experience
- Experience in writing professional reports
- Prior experience interacting with regulatory entities
- Previous experience in quality improvement measures
- Data collection and analysis
- Experience with Google Suite Applications
Conditions of Employment- A preemployment criminal background check will be conducted as part of the selection process as this position is deemed to have direct contact with vulnerable persons. Felony convictions conviction of crimes of moral turpitude or convictions of misdemeanors related to job duties may disqualify you from being considered for this position. Should your background check reveal any charges or convictions it is your responsibility to provide the CDHS Background Unit with an official disposition of any charges.
- A Tuberculosis Test (TB) will be required upon hire
- May work weekends or alternate shifts/schedules
- Shall not initiate or engage in sexual social personal or financial relationships with patients either during or any time after hospitalization even if the patient requests or initiates such relationship.
- Successfully pass all modules of the CMHHIP New Employee Orientation core curriculum to include English reading comprehension relevant competency assessments and written/practical exams;
- Work in situations involving assaultive behavior;
- Former State employees who were disciplinarily terminated or resigned in lieu of termination must disclose the information on the application and provide an explanation why the prior termination or resignation should not disqualify the applicant from the current position. Absent extraordinary circumstances prior disciplinary termination or resignation in lieu of termination will disqualify the applicant from future State employment with CDHS.
Appeal Rights:
If you receive notice that you have been eliminated from consideration for this position you may file an appeal with the State Personnel Board or request a review by the State Personnel Director.
An appeal or review must be submitted on the official appeal form signed by you or your representative. This form must be delivered to the State Personnel Board by email () postmarked in US Mail or hand delivered (1525 Sherman Street 4th Floor Denver CO 80203) or faxed (303.866.5038) within ten (10) calendar days from your receipt of notice or acknowledgement of the departments action.
For more information about the appeals process the official appeal form and how to deliver it to the State Personnel Board; go to; contact the State Personnel Board for assistance at (303); or refer to 4 Colorado Code of Regulations (CCR) 8011 State Personnel Board Rules and Personnel Directors Administrative Procedures Chapter 8 Resolution of Appeals and Disputes atunder Rules.
Supplemental Information
For additional recruiting questions please contact @
About Us:If your goal is to build a career that makes a difference consider joining the dedicated people of theColorado Department of Human Services(CDHS). Our professionals strive to design and deliver high quality human and health services that improve the safety independence and wellbeing of the people of Colorado. In addition to a great location and rewarding and meaningful work we offer:
Strong secure yet flexible retirement benefits including aPERA Defined Benefit Plan or PERA Defined Contribution Planplus 401(k) and 457 plans
Employer supplementedHealth Savings Account
Paid life insurance
Short and longterm disability coverage
11 paid holidays per year plus vacation and sick leave
Excellent worklife programs such as flexible schedules training and more
Remote work arrangements for eligible positions
*Some positions may qualify for the Public Service Loan Forgiveness Program. For more
information go to Values:
We believe in a peoplefirst approach:To serve the people of Colorado we develop a culture and work environment that creates an energized inspired and healthy team capable of giving their best to Coloradans.
Balance creates quality of life:We want our team to be resilient through a supportive workplace that values flexibility health and wellness and employee engagement.
We hold ourselves accountable:We take responsibility through our actions programs and results for the state of health and human services in Colorado.
Transparency matters:We are open and honest with employees our partners the Coloradans we serve and the public.
We are ethical:We abide by what is best for those we serve by doing what is right not what is easy.
Collaboration helps us rise together:We work together with all partners employees and clients to achieve the best outcomes for Coloradans.
We are committed to increasing the diversity of our staff and providing culturally responsive programs and services. Therefore we encourage responses from people of diverse backgrounds and abilities.
ADAA Accommodations:CDHS is committed to the full inclusion of all qualified individuals. As part of this commitment our agency will assist individuals who have a disability with any reasonable accommodation requests related to employment including completing the application process interviewing completing any preemployment testing participating in the employee selection process and/or to perform essential job functions where the requested accommodation does not impose an undue hardship. If you have a disability and require reasonable accommodation to ensure you have a positive experience applying or interviewing for this position please direct your inquiries to our ADAA Coordinator Nancy Schmelzer at or call.Toll Free Applicant Technical Support
THE CAMPUS OF THE COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO IS TOBACCO FREE.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
