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Conduct comprehensive audits of medication administration records (MAR/eMAR/QMAR) to ensure medication accuracy and compliance.
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Review QMAR documentation daily to identify medication discrepancies, omissions, documentation errors, and compliance concerns.
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Perform medication chart audits and medication storage inspections.
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Audit nursing documentation for completeness, accuracy, timeliness, and regulatory compliance.
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Conduct routine clinical record reviews, including admissions, physician orders, treatment plans, medication records, and discharge documentation.
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Ensure all clinical documentation meets federal, state, payer, and accreditation requirements.
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HIPAA
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DHHS Regulations
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CMS Standards
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CARF Standards
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Joint Commission Standards
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North Carolina Behavioral Health Regulations
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Other applicable state and federal regulations
Remain current on regulatory changes and communicate updates to leadership.
Quality Assurance & Performance Improvement
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Participate in organizational Quality Improvement (QI) initiatives.
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Identify compliance trends and recurring deficiencies.
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Develop corrective action plans.
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Monitor implementation and effectiveness of corrective actions.
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Assist leadership with preparation for audits, licensing reviews, accreditation surveys, and inspections.
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Participate in internal mock surveys and compliance readiness activities.
Provide intentional, observation-based clinical education to improve staff performance.
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Conduct medication compliance training once each month at both the Wake County and Pitt County locations.
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Train Paraprofessionals (PPs), Qualified Professionals (QPs), and clinical staff on medication administration standards, documentation requirements, infection control, and regulatory expectations.
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Provide immediate coaching following observed deficiencies.
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Develop individualized education based upon staff performance and identified trends.
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Serve as a clinical resource by proactively addressing staff questions and concerns before they become compliance issues.
Incident Investigation
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Medication errors
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Medication omissions
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Clinical incidents
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Documentation deficiencies
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Compliance violations
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Reportable events
Provide findings, recommendations, and corrective actions to leadership.
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Develop new compliance policies.
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Review existing clinical policies.
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Update procedures based on regulatory changes and organizational needs.
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Recommend process improvements that strengthen compliance and improve patient outcomes.
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Correct identified deficiencies
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Improve clinical processes
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Strengthen regulatory readiness
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Reduce organizational risk
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Enhance quality of care
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Clinical staff
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Executive leadership
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Regulatory agencies
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Surveyors
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External healthcare partners
Travel Requirements
Travel is required.
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Travel between Wake County and Pitt County.
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Travel to the Pitt County location a minimum of twice per month.
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Conduct onsite medication cart audits and compliance reviews.
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Attend meetings as requested by executive leadership.
Reliable transportation is required.
Crandell’s Enterprises Inc., offers a unique combination of premier home health care for individuals suffering from mental disorder, substance abuse and development disabilities. Founded in 2002 by CEO Mary Ann Crandell, the mission is to ensure their adult patients who suffer from mental illness, developmental disabilities and chemical dependence, have the resources, medical treatment and housing they need. The services offered range from adult family care to home psychiatric assistance and mental health services.
