Director of Hospice Regulatory and Quality

Graham Healthcare Group•Warrendale, PA

1d•Onsite

About The Position

Maintain responsibility for all Quality activities of the organization. Accountable for the monitoring, implementation, and evaluation of processes and programs to meet regulatory, accreditation, and standards of practice. Plan, execute, and finalize projects under the guidance of the Vice President of Clinical Operations, including acquiring resources, coordinating efforts of team members, defining objectives, and overseeing quality control throughout projects to ensure completion. Serves as backup administrator. Essential Duties and Responsibilities include the following. Other duties may be assigned as necessary. Implement and monitor the organization’s quality assessment performance improvement (QAPI) program Direct and coordinate quality improvement activities utilizing continuous quality improvement principles and methodologies Ensure that there are processes in place to monitor and measure all activities related to QAPI Establish a process model for improvement and provides education and training to organization personnel on QAPI plan and team development Coordinate activities related to clinical record review for data collection Compile, trend, and report quality data in patient care, safety, risk management, infection control, outcomes, and customer satisfaction Collaborate with Nursing Supervisors to ensure documentation is complete and consistent with care and reflects legal requirements Ensure processes to monitor and evaluate safety, risk management, and infection control programs Coordinate, educate, and implement monitoring activities for safety, risk management, and infection control Collaborate with management in follow-up of concerns expressed by patients, families, and physicians Maintain current knowledge related to home care safety and infection control standards Collaborate with Nursing Supervisors to provide a process to promote and ensure employee orientation, competency, and in-service education programs Assist in the identification of skills for annual competence and provide in-service training support Collect data on records of employee orientation and annual competency requirements as part of the QAPI plan Monitor organization compliance with regulatory and accreditation standards Maintain current knowledge related to Medicare Conditions of participation and the Accreditation Commission for Healthcare (ACHC) standards to ensure that the organization is compliant with state, federal, and accreditation guidelines Act as a resource to Supervisors regarding standards, policies, and regulations and provide in-service training to leadership and staff as needed in these areas Maintain updated nursing knowledge and skills Responsible for HCHB workflow related to Quality, pushing admissions and processing discharges Assisting with the overall development and implementation of the QAPI program Assisting in the identification of goals and related patient outcomes Coordinating, participating and reporting of activities and outcomes May assist with administrative on-call during after hours, if needed Comply with Company’s Core Values and Core Competencies Perform other duties as assigned Administrator Duties In the absence of the Administrator/ Vice President of Operations, the Director of Regulatory and Quality Assurance will assume/ fulfill the duties of the Administrator. Duties are as follow: Be Appointed by and report to the governing body Be responsible for all day to day operations of the hospice agency Ensure that a clinical manager as described in paragraph (c) of section 484.105(b)(1)of the Conditions of Participation is available during all operating hours. Ensure that the hospice agency employs qualified personnel, including assuring the development of personnel qualifications and policies. Organizes and directs the hospice services ongoing day to day operations Mains ongoing liaison among owner and personnel Ensures adequate personnel education and evaluations Ensures the accuracy of public information materials and activities Implements an effective budgeting and accounting system Available during all operating hours for patient service delivery needs or personnel needs All other duties as assigned by the Administrator/ Vice President.

Requirements

Bachelor’s degree in Nursing required
3-5 years of experience in healthcare management
Excellent understanding of performance improvement, quality assessment, and utilization management
Competency and proficiency in understanding QAPI and ACHC
Solid working knowledge of current systems
Demonstrated experience in personnel management
Experience working both independently and in team-oriented, collaborative environment is essential
Can conform to shifting priorities, demands, and timelines through analytical and problem-solving capabilities
Able to respond to project adjustments and alterations promptly and efficiently
Flexible during times of change
Strong written and oral communication skills
Strong interpersonal skill
Strong customer service skills
Good team building skills
Self-directed and able to work with minimal supervision
Must have and maintain in good standing professional license, certificate, or registration, as applicable.

Nice To Haves

Master’s preferred

Responsibilities

Implement and monitor the organization’s quality assessment performance improvement (QAPI) program
Direct and coordinate quality improvement activities utilizing continuous quality improvement principles and methodologies
Ensure that there are processes in place to monitor and measure all activities related to QAPI
Establish a process model for improvement and provides education and training to organization personnel on QAPI plan and team development
Coordinate activities related to clinical record review for data collection
Compile, trend, and report quality data in patient care, safety, risk management, infection control, outcomes, and customer satisfaction
Collaborate with Nursing Supervisors to ensure documentation is complete and consistent with care and reflects legal requirements
Ensure processes to monitor and evaluate safety, risk management, and infection control programs
Coordinate, educate, and implement monitoring activities for safety, risk management, and infection control
Collaborate with management in follow-up of concerns expressed by patients, families, and physicians
Maintain current knowledge related to home care safety and infection control standards
Collaborate with Nursing Supervisors to provide a process to promote and ensure employee orientation, competency, and in-service education programs
Assist in the identification of skills for annual competence and provide in-service training support
Collect data on records of employee orientation and annual competency requirements as part of the QAPI plan
Monitor organization compliance with regulatory and accreditation standards
Maintain current knowledge related to Medicare Conditions of participation and the Accreditation Commission for Healthcare (ACHC) standards to ensure that the organization is compliant with state, federal, and accreditation guidelines
Act as a resource to Supervisors regarding standards, policies, and regulations and provide in-service training to leadership and staff as needed in these areas
Maintain updated nursing knowledge and skills
Responsible for HCHB workflow related to Quality, pushing admissions and processing discharges
Assisting with the overall development and implementation of the QAPI program
Assisting in the identification of goals and related patient outcomes
Coordinating, participating and reporting of activities and outcomes
May assist with administrative on-call during after hours, if needed
Comply with Company’s Core Values and Core Competencies
Perform other duties as assigned
Be Appointed by and report to the governing body
Be responsible for all day to day operations of the hospice agency
Ensure that a clinical manager as described in paragraph (c) of section 484.105(b)(1)of the Conditions of Participation is available during all operating hours.
Ensure that the hospice agency employs qualified personnel, including assuring the development of personnel qualifications and policies.
Organizes and directs the hospice services ongoing day to day operations
Maintains ongoing liaison among owner and personnel
Ensures adequate personnel education and evaluations
Ensures the accuracy of public information materials and activities
Implements an effective budgeting and accounting system
Available during all operating hours for patient service delivery needs or personnel needs
All other duties as assigned by the Administrator/ Vice President.