Director of Quality and Compliance

JOB SUMMARY AND SCOPE: The Director of Quality and Compliance (DQC) develops, implements, and maintains an effective and ongoing hospice-wide, data-driven Quality Assessment Performance Improvement Plan that meets the CMS/Joint Commission Standards: Program Scope, Program Data, Program Activities, and Performance Improvement Projects. The DQC will report to the QAPI Committee on the findings from Quality Assurance audits.

The Director of Quality and Compliance is responsible for overseeing the administration and implementation of the Compliance Program for Hospice of San Joaquin. The DQC shall report quarterly to the QAPI Committee on the operation and findings of the Legal Compliance Program. As such, the DQC will have broad autonomy to review any aspects of Hospice of San Joaquin’s billing, charting, and other Agency areas as the DQC deems appropriate to determine the level of Hospice of San Joaquin’s Compliance Program. The DQC shall report to the CEO regarding all day-to-day personnel issues, but to the Board of Directors for Compliance Complaints and investigations.

QUALITY IMPROVEMENT: Responsible for the implementation and monitoring of the organization’s quality assessment performance improvement (QAPI) program, including infection control and OSHA.

a) Defines data elements, plans, prepares, and leads the quarterly Quality Assessment Performance Improvement (QAPI) meetings. Provides direction and coordination of QAPI activities utilizing continuous quality improvement principles and methodologies.

b) Compiles, trends, analyzes, and reports quality data in the following areas: patient care, safety, risk management, infection control, outcomes, HR, Volunteer, billing, and customer satisfaction. When a GAP is present, develops a PIP. Data is analyzed and compared internally and externally with other sources when available.

c) Develops and tracks ongoing Agency Performance Improvement Projects (PIPs) and designates appropriate managers or staff to conduct performance improvement projects, based on QAPI and benchmarking data.

d) Facilitates comprehensive chart audits for ALL teams and programs, utilizing the Hospice Clinical Record Audit Tool by the Joint Commission.

e) Works collaboratively with nursing supervisors to ensure documentation is complete and consistent with care and reflects legal requirements. Performs Clinical on-site visits to audit adherence to Conditions of Participation as needed.

f) Investigates and tracks serious adverse events/incidents/unusual occurrences, develops corrective action plans in conjunction with the CEO and CCO, and reports as appropriate to outside agencies.

g) Collaborates with management staff in the follow-up of concerns expressed by patients, families, and physicians.

h) Maintains the agency’s Required Reports Document and follows up with directors monthly to ensure compliance with all reports. All non-compliance items are reported to the CEO.

i) Oversees the HIS data comparison and the Hospice CAHPS submissions.

Education

Designs and oversees the staff education program, and ensures all compliance items are met. Collaborates with Clinical Educators to provide a process to promote and ensure employee orientation, competency (skills lab), and in-service education programs. Ensuring that these programs remain updated to changes in regulations, and in response to employee surveys, CAHPS scores, and PIPs.

j) Assists in the identification of skills for annual competency and provides in-service training support.

k) Ensures HHA/CNA are compliant with State CEU requirements.

l) Maintains agency CEU Licensing program. Coordinates with CCO and Medical Director to provide two (2) CEU courses a year.

m) Oversees the administration of the Relias education system.

COMPLIANCE: As Compliance Officer, ensures compliance plan includes all elements, compliance line is available for staff and patient reporting, and investigates issues. Monitor organization compliance with regulatory and accreditation standards.

n) Maintains current knowledge related to Medicare Conditions of Participation and the Joint Commission’s standards to ensure that the organization is compliant with state, federal, and accreditation guidelines.

o) Responsible for ensuring clinical policies and procedures (including emergency management) for ALL programs reflect all related local, state, federal, and Joint Commission standards and make recommendations for policy changes to the governing board and the IDG.

p) Facilitates clinical policy approval for new and revised policies through the Senior Leadership team and the IDG. Review policies and procedures annually with the IDG.

q) Ensures all Clinical Policy Manuals are archived electronically.

r) Acts as a resource to Clinical Supervisors/Nursing Supervisors regarding standards, policies, and regulations, and provides in-service training to leadership and staff as needed in these areas.

s) Member of the forms committee, responsible for ensuring ALL clinical forms maintain regulatory requirements before being implemented or changed.

t) Accept and review all suspected compliance violations as reported by staff, volunteers, or derived from audits.

u) Monitor and review all suspected compliance violations as reported to Guidance Line, a company that accepts anonymous compliance-related communication from employees and volunteers. v) Provide an annual Compliance Report for the Board of Directors.

w) Ensures the EMR system maintains compliance with changing Medicare Conditions of Participation and the Joint Commission’s standards to ensure that the organization is compliant with state, federal, and accreditation guidelines.

ACCREDITATION/JOINT COMMISSION SURVEY: Understand the regulations and requirements for State, the Joint Commission, and Kaiser certification/licensure. Leads preparation of agency for TJC accreditation, California Department of Public Health surveys, and annual Kaiser site visits. Acts as liaison with the surveyor and assures that the surveyor has the needed staff (managers) for the interviews and the needed documentation. Assures the plan of correction is completed and submitted promptly to the surveying authority after approval of CCO and CEO.

SAFETY AND INFECTION CONTROL OFFICER: Responsible for ensuring processes to monitor and evaluate safety, risk management, and infection control programs.

z) Coordinates, educates, and implements monitoring activities for safety, risk management, and infection control.

aa) Coordinates mandatory in-service programs on OSHA regulations for safety and infection control.

bb) Acts as a resource to staff in identifying safety and risk management issues for patients and staff.

cc) Maintains current knowledge related to home care safety and infection control standards.

Leadership - Promote self-growth and collegial relationships with others in the home care industry.

dd) Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal and professional networks, and participating in professional organizations or societies.

Qualifications, skills, and

Experience

• Current RN, BSN license

2 Five years of Hospice experience - preferred

• Reliable transportation, including a valid California driver’s license, proof of active auto insurance, and an acceptable driving record.

• Ability to meet the job’s physical demands (i.e., kneeling, squatting, bending, lifting.

• Knowledge/experience using any EMR (Electronic Medical Records) system is recommended.

Pre-employment

Requirements

• Health Screening

• Background Check

• Reference Check

• Drug Screening

• Immunization records – part of the terms and conditions of employment.

We offer a great benefits package to our staff, such as

• Competitive hospice industry compensation
• Benefits package with multiple plan offerings and generous employer contribution
• 401(k) Retirement plan with employer match
• AFLAC insurance plans
• Flexible Spending Account (FSA)
• Fitness Center membership discount
• Employee Assistance Programs (ESP)
• Supportive work culture which encourages work-life balance
• Paid Time Off (PTO)
• Monthly mileage reimbursement
• Employee Referral Program

If you are interested in being part of a dynamic team and helping us continue to be the leader in ensuring the quality of the journey, from a serious illness through end of life, and to honor our mission by honoring life by ensuring patients and their Caregivers are the focus of everything we do, we encourage you to apply. To learn more about Hospice of San Joaquin, please visit our website at: www.hospiceofsanjoaquin.org