Essential Job Functions:
Monitoring and Evaluation Activities
Conduct quality audits of ICL and affiliate program sites on a monthly, quarterly, annual or as needed basis to determine conformance to regulatory agency, accrediting agency and ICL standards for service delivery;
- Conduct audits of the implementation of plans of corrective action that have been developed by programs in response to statements of deficiencies pursuant to regulatory agency program audits;
- Conduct clinical case or business record reviews;
- Conduct physical plant surveys;
- Conduct employee interviews;
- Conduct recipient interviews;
- Conduct billing compliance audits; and
- Conduct contract compliance audits as appropriate.
Assist in the administration of various department quality assurance and improvement information systems where administration includes responsibility for data entry, reliability of database records, and statistical and other reports that produced from the database including but not limited Consumer evaluation surveys.
Participate in reviews and analyses of quality-of-care-related data and program-performance data to determine progress toward stated goals and objectives.
Participate in ICL and affiliate incident management programs:
- Conduct special investigations of serious reportable incidents and allegations of abuse;
- Participate in the maintenance of ICL and oversight agency databases by entering data from incident reports and producing reports from the databases; and
- Generate Incident Review Committee meeting agenda and other reports on an as needed basis.
Participate in the design, production and use of quality assurance and improvement instruments (e.g. internal audit tools) and quality improvement products (e.g. manuals, training guides); and
Issue requested management reports on identified quality assurance and improvement performance and outcome indicators.
- Assist ICL and affiliate program managers and staff in preparation for accreditation and recertification;
- Assist ICL and affiliate program managers with achieving conformance to Federal, State, City and accreditation agency standards through participation in planning activities and development of quality and compliance-related products and processes;
- Participate in development of ICL and affiliate electronic clinical information systems, providing consultation to program staff in use of the agency’s EHR to construct assessments, treatment plans, and quality audit products; and
- Engage in problem-solving activities with program managers and/or staff to improve program effectiveness and the quality of care.
- Participate in design and delivery of workshops and other educational materials to program managers and staff that provide knowledge and information on accrediting, regulatory and professional standards and practices that pertain to evidence-based service delivery and quality of care for existing and new programs.
- Represent the agency at relevant conferences by designing and presenting educational materials and activities that promote continuous quality improvement.
- Participate in or conduct or coordinate root cause analyses on sentinel and other significant events in programs on an as-needed basis.
- Teach or provide oversight to assigned practicum or internship students.
Relationships with Others in the Agency
- Consult with program directors and residence managers to develop and execute quality improvement plans, including plans of corrective action (POCAs) for certification visits and internal agency audit reports.
- Participate in program planning projects and meetings to provide input on development of quality control and program evaluation elements.
- Conduct or participate in management meetings with service-delivery program managers to establish, delineate, and review program organizational policies, to coordinate functions and operations between departments, and establish responsibilities and procedures for attaining objectives and assist with the implementation of new programs.
- Perform other related duties as assigned.