Quality Improvement/ Compliance Director

Reporting to the Chief Executive Officer and in collaboration with the Chief Nursing Officer, is responsible for, but not limited to, developing, implementing and maintaining an effective, ongoing, comprehensive and data driven quality assessment and performance improvement (QAPI) program for the organization and its related entities. Assures compliance with staff education requirements and NYS approved training curriculums. Will prepare and recommend the overall Quality Improvement (QI) and QAPI plan documents for adoption/revision on a timely basis; insure ongoing policy development and annual review as required; maintain a focus on compliance with regulatory requirements pertaining to quality care delivery as well as in response to identified needs; promote opportunities for input from persons served and other constituencies with regard to quality improvement issues; provide comprehensive and effective response to any identified deficiencies; provide supervisory oversight for QI staff in conducting required clinical record reviews and with all QI activities. Serves as the organization's Compliance Officer and Privacy Officer, as well as key staff leadership for the QI committee(s) of the governing authority.

RESPONSIBILITIES:

1. Lead the development, implementation, and ongoing evaluation of QAPI and quality improvement (QI) initiatives for both HomeCare & Hospice and Total Senior Care.
2. Revise and update QAPI and compliance plans annually and as needed to meet regulatory standards.
3. Oversees the collection. Analysis, and reporting of quality data, including clinical outcomes, patient satisfaction, and incident reports.
4. Promotes a culture of patient safety by developing and enforcing risk mitigation, policies and procedures.
5. Serve as the lead for quality committees (e.g., Risk Management, Corporate QI, QAPI) and supervise quality improvement staff.
6. Provide oversight of data management, electronic health records, and regulatory submissions (e.g., Hospice Item Set (HIS), CAHPS) with quality and compliance.
7. Identify areas for improvement and implement evidence-based best practice solutions to enhance care delivery and operational efficiency.
8. Facilitate survey readiness and lead the organization through survey readiness, accreditations, and licensure processes in collaboration with the Chief Nursing Officer.
9. Supervise patient satisfaction surveys, staff education programs and incident reporting processes.
10. Collaborate with HR, CNO, Education Coordinator, senior team, and clinical teams to ensure compliance with staff education and clinical training requirements.
11. Develops, revises and ensures required review of policies and procedures in collaboration with the CNO.

1. Acts as Compliance Officer and Privacy Officer, ensuring adherence to all relevant regulations including Medicare, Medicaid, CMS, DOH, NHPCO, and HIPAAA.
2. Oversees the organization's compliance program, conducting internal audits and reviews.
3. Stay up to date with healthcare legislation and provide staff training and regulatory changes.
4. Maintain communication with regulatory agencies and lead the organization through accreditation and compliance surveys.
5. Ensure appropriate response to complaints, grievances, and regulatory findings.
6. Oversees the organization's emergency and disaster preparedness plan, conducting drills and maintaining readiness in collaboration with the CNO.
7. Collaborates with clinical teams to integrate quality and compliance measures into daily operations.
8. Provide training and education on quality improvement and regulatory compliance at all levels of the organization.
9. Lead the QAPI committee and other relevant workgroups to drive organizational improvement.
10. Develop and implement corrective action plans to address compliance issues identified in surveys or audits.
11. Support the professional growth of clinical and administrative staff through ongoing coaching and training.
12. Oversee incident reporting, root cause analysis, and corrective action planning.
13. Develop policies and protocols to mitigate clinical, operational, and financial risks.
14. Ensure patient grievances and complaints are addressed in accordance with regulatory guidelines and report timely and appropriately.
15. Adheres to and reflects organizational values in daily work. Serves on agency committees as may be assigned.
16. Maintains a professional obligation to report wrongdoing/violation of agency policies, applicable federal, state and local laws, and rules and regulations pertaining to agency operations, to immediate supervisor.
17. Completes all mandatory inservice education programs, participates in appropriate education and training programs appropriate for the position, and completes other inservice hours that are minimally required.

The above examples of work may not be a complete statement of all assignments that may be inherent to the position. Other duties may also be assigned as deemed necessary and appropriate by the CEO and in accordance with the CNO.

MINIMUM REQUIREMENTS:

1. Bachelor's degree in nursing, Healthcare Administration, Public Health, or a related field. Master's degree is preferred
2. Current RN license preferred, current LPN license or relevant healthcare licensure.
3. Certification in healthcare quality or compliance preferred.
4. Four years nursing experience, preferably in hospice or homecare with at least 2 years of the minimum required experience involved with the management and/or delivery of quality improvement programs, studies, or initiatives.
5. Knowledge of quality improvement program design, execution, and reporting. Knowledge of federal and state hospice/home care/ PACE regulations preferred.
6. Demonstrated supervisory and organization skills.
7. Computer literacy and knowledge of word processing and database programs; Microsoft office experience and literacy preferred; experience or demonstrated ability to work with electronic medical records.
8. Effective verbal and written communication skills.
9. Acceptable driver's license and automobile available for use with current insurance.
10. Availability by telephone.