Nhtcinc
Description
GENERAL SUMMARY
Coordinates/Leads the Agency’s Continuous Quality/Performance Improvement to ensure a proactive approach to the revision, provision and development of treatment services that meet or exceed compliance with accrediting standards (CARF), other regulatory bodies and the Agency’s strategic plans. Ensures Agency’s required codes of ethics and values are practiced in daily operations.
MINIMUM QUALIFICATIONS
Master’s in Behavioral Health Science with 3 years of experience in Quality Improvement and Accreditation
And/or Bachelor’s Degree in Behavioral Health Science with 5 years of experience both required to have CARF survey experience.
Requirements
I.
Coordinate and facilitate the Agency-wide Quality Improvement Program including but not limited to: Collaborates with the Clinical Quality Assurance Director to ensure that there is a written annual plan for the Quality Improvement Plan which describes the Agency’s performance goals, areas needing improvement, strategies to achieve ,
and ongoing mechanisms to review, renew, or revise goals, strategy or tactics. Develops/revises Agency-wide written policy and procedures, other documents, written plans as required by external accreditation or other regulatory entities. Ensures Agency stays informed of changes and remains current and in compliance with all regulatory requirements. Chairs the Quality Improvement Committee and oversees all sub committees. Continually monitors and evaluates the Quality Improvement program and implements corrective actions as needed to achieve optimal outcomes. Chairs the Recovery Oriented System of Care Committee. Collaborates with the Clinical Quality Assurance Director to facilitate internal ROSC chart audits and client interviews. Provides direction to various Agency departmental groups with regard to their respective Quality Improvement activities, monitors compliance and reports deficiencies to QI Committee. Serves as the central coordinating point for all contract monitoring, corrective action and performance improvement plans. Collaborates with the Clinical Director and Information Technology Director to develop and maintain automated databases for Quality/Performance and accreditation data; provides periodic statistical and summary reports as required. Oversees Risk Management/ Facilities and Safety Responsible for agency licensing renewals II.
Participates in all Agency Quality Improvement committees and sub-committees as directed: Provides directions for the continuous Quality Improvement committee as appropriate. In conjunction with the appropriate Quality Improvement committee(s), continually reviews data related to service delivery in order to determine committee agenda(s) and identifying areas requiring further support, training, review or revision. Tracks, monitors the status of identified problems to ensure their improvement or resolution. Maintains Quality Improvement tracking systems for all committee meetings reflecting issues discussed recommended action, follow-up status and the designated party (ies) responsible for the appropriate follow-up. III.
Coordinates,
Coordinates, gathers, disseminates and documents information to facilitate compliance with requirements for accreditation surveys and other regulatory and contract entities: Effectively plans and coordinates the preparation of on-site accreditation and monitoring surveys. Demonstrates effectiveness in presenting and/or providing information to program managers,as needed, to assure compliance with accreditation/statutory/contract requirements and/or standards. Provides assistance to staff in monitoring and evaluating the performance of care intheir respective programs; assists in the development and revision of policies as required and/or indicated. Maintains current knowledge of accreditation standards and the survey process for the Commission on Accreditation of Rehabilitation Facilities (CARF). Effectively provides ongoing information to management on Quality/Performance activitiesand provides timely status reports on accreditation preparedness, CAPs and other related issues. This position will oversee the staff who is assigned as the official Single Point of Contact, which is designated to coordinate the provision of auxiliary aids and services to the deaf and hard of hearing. IV.
Participates in the Corporate Compliance Program for the Organization. Assistswith audit procedures are implemented in accordance with New Horizons’ audit policies. Assists with investigations of client/employee complaints/grievances and other concerns regarding compliance, as requested. Participates in administrative committees and meetings and community relations activities. V.
Coordinates,gathers and analyzes all client grievances for the agency: Ensures that all grievances are entered into the EHR System. Reviews grievances, communicates with individuals who submit the grievances, and assigns them to a manager to be reviewed. Ensuresthat all necessary time frames are complied with. Identifies any trends within the grievances and provides additional training when necessary. Reportsmonthly on compiled information to appropriate Quality Improvement sub-committee and recommends any follow up necessary. VI.
Supervises Medical Records Staff: Demonstrates knowledge of the legal aspects, including the liabilities of patient/client medical records. Demonstrates an understanding of the laws pertaining to confidentiality and the release of medical records information ensuring that agency policies and procedures are within the legal boundaries and guidelines as established by applicable Florida Statute(s) and Administrative Code(s) and the Federal Substance Abuse Regulations. All "on the job" and "off the job" activities are performed in accordance with the Agency's Client Confidentiality standards. Works with and supervises Medical Records Staff, providing leadership and direction as needed. VII.
Serves as the Privacy Officer for the agency as required under Health Information Portability and Accountability Act (HIPAA) Receives and responds to complaints regarding potential violations of confidentiality and provides additional information as required. Works cooperatively with various Agency departments after receiving noticesrequesting to inspect, amend, and restrict access to protected health information and provides additional information as required. Develop and implement the Agency’s privacy policy and procedures Performs periodic privacy monitoring activities. Provides the initial privacy training as part of orientation to all employees. Works with management, key departments, and committees to ensure the organization has and maintains appropriate privacy and confidentiality consent, authorization forms, and privacy notices that reflect current legal practices and requirements. Participates in the development, implementation, and ongoing compliance monitoring of all business associate agreements, to ensure all privacy concerns, requirements, and responsibilities are addressed. VIII.
Oversees Internal Incident Reporting and Analysis System (IRAS) process · Oversees all Grievances · Submits timely reporting into States IRAS/CARF database · Follows up on inquiries and questions from SEFBHN/DCF regarding IRAS submissions in a timely manner. · Follows up with Program Managers on follow up actions and performance improvements plans when appropriate. · Tracks trends and reports to Quality Assurance committee. · Makes necessary policy revisions or suggested trainings from IR date
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Coordinate and facilitate the Agency-wide Quality Improvement Program including but not limited to: Collaborates with the Clinical Quality Assurance Director to ensure that there is a written annual plan for the Quality Improvement Plan which describes the Agency’s performance goals, areas needing improvement, strategies to achieve ,
and ongoing mechanisms to review, renew, or revise goals, strategy or tactics. Develops/revises Agency-wide written policy and procedures, other documents, written plans as required by external accreditation or other regulatory entities. Ensures Agency stays informed of changes and remains current and in compliance with all regulatory requirements. Chairs the Quality Improvement Committee and oversees all sub committees. Continually monitors and evaluates the Quality Improvement program and implements corrective actions as needed to achieve optimal outcomes. Chairs the Recovery Oriented System of Care Committee. Collaborates with the Clinical Quality Assurance Director to facilitate internal ROSC chart audits and client interviews. Provides direction to various Agency departmental groups with regard to their respective Quality Improvement activities, monitors compliance and reports deficiencies to QI Committee. Serves as the central coordinating point for all contract monitoring, corrective action and performance improvement plans. Collaborates with the Clinical Director and Information Technology Director to develop and maintain automated databases for Quality/Performance and accreditation data; provides periodic statistical and summary reports as required. Oversees Risk Management/ Facilities and Safety Responsible for agency licensing renewals II.
Participates in all Agency Quality Improvement committees and sub-committees as directed: Provides directions for the continuous Quality Improvement committee as appropriate. In conjunction with the appropriate Quality Improvement committee(s), continually reviews data related to service delivery in order to determine committee agenda(s) and identifying areas requiring further support, training, review or revision. Tracks, monitors the status of identified problems to ensure their improvement or resolution. Maintains Quality Improvement tracking systems for all committee meetings reflecting issues discussed recommended action, follow-up status and the designated party (ies) responsible for the appropriate follow-up. III.
Coordinates,
Coordinates, gathers, disseminates and documents information to facilitate compliance with requirements for accreditation surveys and other regulatory and contract entities: Effectively plans and coordinates the preparation of on-site accreditation and monitoring surveys. Demonstrates effectiveness in presenting and/or providing information to program managers,as needed, to assure compliance with accreditation/statutory/contract requirements and/or standards. Provides assistance to staff in monitoring and evaluating the performance of care intheir respective programs; assists in the development and revision of policies as required and/or indicated. Maintains current knowledge of accreditation standards and the survey process for the Commission on Accreditation of Rehabilitation Facilities (CARF). Effectively provides ongoing information to management on Quality/Performance activitiesand provides timely status reports on accreditation preparedness, CAPs and other related issues. This position will oversee the staff who is assigned as the official Single Point of Contact, which is designated to coordinate the provision of auxiliary aids and services to the deaf and hard of hearing. IV.
Participates in the Corporate Compliance Program for the Organization. Assistswith audit procedures are implemented in accordance with New Horizons’ audit policies. Assists with investigations of client/employee complaints/grievances and other concerns regarding compliance, as requested. Participates in administrative committees and meetings and community relations activities. V.
Coordinates,gathers and analyzes all client grievances for the agency: Ensures that all grievances are entered into the EHR System. Reviews grievances, communicates with individuals who submit the grievances, and assigns them to a manager to be reviewed. Ensuresthat all necessary time frames are complied with. Identifies any trends within the grievances and provides additional training when necessary. Reportsmonthly on compiled information to appropriate Quality Improvement sub-committee and recommends any follow up necessary. VI.
Supervises Medical Records Staff: Demonstrates knowledge of the legal aspects, including the liabilities of patient/client medical records. Demonstrates an understanding of the laws pertaining to confidentiality and the release of medical records information ensuring that agency policies and procedures are within the legal boundaries and guidelines as established by applicable Florida Statute(s) and Administrative Code(s) and the Federal Substance Abuse Regulations. All "on the job" and "off the job" activities are performed in accordance with the Agency's Client Confidentiality standards. Works with and supervises Medical Records Staff, providing leadership and direction as needed. VII.
Serves as the Privacy Officer for the agency as required under Health Information Portability and Accountability Act (HIPAA) Receives and responds to complaints regarding potential violations of confidentiality and provides additional information as required. Works cooperatively with various Agency departments after receiving noticesrequesting to inspect, amend, and restrict access to protected health information and provides additional information as required. Develop and implement the Agency’s privacy policy and procedures Performs periodic privacy monitoring activities. Provides the initial privacy training as part of orientation to all employees. Works with management, key departments, and committees to ensure the organization has and maintains appropriate privacy and confidentiality consent, authorization forms, and privacy notices that reflect current legal practices and requirements. Participates in the development, implementation, and ongoing compliance monitoring of all business associate agreements, to ensure all privacy concerns, requirements, and responsibilities are addressed. VIII.
Oversees Internal Incident Reporting and Analysis System (IRAS) process · Oversees all Grievances · Submits timely reporting into States IRAS/CARF database · Follows up on inquiries and questions from SEFBHN/DCF regarding IRAS submissions in a timely manner. · Follows up with Program Managers on follow up actions and performance improvements plans when appropriate. · Tracks trends and reports to Quality Assurance committee. · Makes necessary policy revisions or suggested trainings from IR date
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