Job Description:

Position Summary: The Director of Quality Assurance/Performance Improvement (QAPI) and Education is responsible for the oversight of performance improvement and education activities at Visiting Nurse Service and Hospice (VNSHS).
Responsibilities & Duties
Collaborates with the Directors of Intake and Service Development, Patient Services, and Operations in the integration of QAPI and education into clinical services:

Supports a care management model directed at standardizing clinical practice using best practice concepts, improving clinical outcomes, and managing agency resources.
Provides education and monitoring of the development of OASIS into care planning, measuring and analyzing impact on patient care and agency function.
Coordinates the documentation requirements of the Agency with the Clinical Directors and Managers.
Focuses on areas of improvement as delineated in Quality Indicator reports, and benchmarks for the CHHA.
Works collaboratively with the Hospice program QAPI Coordinator to share knowledge, prepare and deliver reports, prepare for regulatory visits, and assure both the CHHA and Hospice programs have oversight with respect to the responsibilities and duties outlined in this job description.

Develops and modifies standards of care and expected outcomes in conjunction with Director Patient Services by:

Ongoing updating of agency policies consistent with sound nursing practice and ensuring regulatory compliance.
Participation in administrative and supervisory meetings for the exchange of information and ideas.
Orientation of new staff regarding established standards and outcomes.
Participating in budgetary planning for the agency.

Ensures regulatory compliance through the monitoring and oversight of compliance with all laws, rules, regulations, and standards, as measured by:

Ensuring that Quality Assurance/Performance Improvement Committee meetings are conducted quarterly as mandated by CMS and the NYS State Department of Health for the Certified Home Health Agency.
Implementation and adherence to CHAP accreditation standards throughout the organization.
Implementation and adherence to Medicare Conditions of Participation, NYS State Department of Health regulations and CHAP standards.
Participation in committees to improve agency outcomes and utilization.
Providing consultation with supervisory staff and/or through home visits to patients.

Oversees and has responsibilities for the performance improvement activities within the agency, and the integration of these activities into practice:

Oversees documentation requirements for the agency regarding best practices and timeliness of documentation, including oversight of accurate use of ICD- 10 coding regulations.
Focuses on areas of improvement as delineated in the agency's quality reporting outcomes and benchmarks per industry standards.
Reviews OASIS Integrity Reports. Ensures the implementation of corrective action as required.
Monitors and evaluates the CHHA program for ongoing relevancy, quality, and appropriateness of services, as delineated in the annual agency evaluation.
Maintains liaison with other community agencies and trade associations to monitor industry response to changes in regulations, payments, and market trends.
Analyzes data and investigates outliers. Follows-up regarding the findings with the appropriate Director/Manager to ensure corrective action is conducted as required.
Identifies the need for Performance Improvement Projects.
Maintains a current QAPI plan to which meets regulatory requirements. Conducts an annual QAPI Program Evaluation.
Chairs the QAPI Committee meetings, prepares findings for reporting and assists in future planning.

Ensures that the educational needs of the agency staff are met. Oversees and coordinates with the Staff Education Coordinator in meeting the agency's educational needs:

Ensures the development and implementation of the Annual Mandatory Inservice education program for all staff.
Ensures that an annual educational needs staff survey is conducted annually. Works closely with the CHHA educators to ensure that educational programs are developed to meet identified needs.
Ensures the annual review/revision of all agency clinical policies and procedures. Initiates the development of new policies in response to new regulations/standards.
Oversees that N95 fit testing is completed on hire and annually thereafter for all direct care staff.

Provides direct supervision of:

QAPI and Education Coordinator
Staff Development and Education Clinical Managers
Additional staff as required or added

Quality Assurance and Performance Improvement

Reviews a sample of patient records for completeness, appropriateness, and compliance with CHHA laws, rules, regulations, and standards.?
Reviews and ensures the timely submission of clinical documentation in response to requests from Medicare for Additional Documentation Requests (ADRs), TPL requests, TPE requests?and/or other types of audit activity.
Reviews and responds timely to Medicare and other payment denials through submission of appeals up to and including the Administrative Law Judge level of appeal.
Reviews Annual QAPI Plans as they apply to the CHHA and Hospice, including review of outcomes of previous year's plan and proposal of goals to be incorporated in subsequent projected Annual QAPI Plans.?
Accesses at a minimum, the CMS, CDC, NYSDOH, Health Commerce System and CHAP websites to obtain the latest information, recommendations, and directives as they apply to the CHHA and Hospice.?Disseminates the latest information, recommendations and directives timely.
Reviews CHHA infection control and incident logs to identify need for Performance Improvement Projects and/or staff education needs in coordination with the CHHA education staff.
Assists as needed in the orientation of new clinical and administrative staff in coordination with the CHHA/Hospice Educators and CHHA/Hospice Directors of Patient Services.?
Collaborates with Hospice QAPI Coordinator regarding Hospice program elements.

Compliance
Reviews and ensures timely response to all requests for copies of clinical documentation including but
not limited to:

Subpoenas and requests for discovery.?
Requests from a Coroner, Medical Examiner, or Funeral Director.?
Public Health Activities:?Given to a public health authority to prevent or control disease.?
Abuse, Neglect or Domestic Violence.?
Oversight activities authorized by Law: Inspection of records by regulatory agencies.?
Oversees the response to patient's request for accounting of disclosures.?
Oversees the response to patient's request for copies of records and or amendments to them.?
Applies for and submits CHAP reaccreditation renewals, including review and updating of related materials.
Represents CHHA as lead contact on NYSDOH and CHAP surveys.
In collaboration with CHHA Educator and CHHA Director of Patient Services, prepares and submits the Plan of Correction response to survey deficiencies cited.?
Initiates and oversees audits necessary to fulfill goals of Plan of Correction.?
Work with Hospice QAPI Coordinator to ensure above objectives are maintained for hospice program.

Qualifications/Special Skills

Demonstrates leadership and decision-making abilities

Committed to the provision of quality care.

Familiar with home care and its implementation

Skilled communicator

Flexible, innovative, and autonomous professional

Adept computer skills and related understanding of software applications

Experience Requirements

Minimum of two years of experience in a supervisory capacity in a Certified Home Health Agency or Hospice, OR 2 years of Home Health or Hospice nursing experience, plus a Master Degree in Nursing, Public Health, Business Administration or another health-related field.

Education/Credentials

Registered Professional Nurse currently licensed in New York State.

Bachelor Degree in Nursing or health related field required; Master degree preferred.

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