Summary of Duties and Responsibilities: Compliance, quality and infection control activities. Includes coordination and/or implementation of quality, compliance and infection control related data collection. Reviews patient records and/or other clinical related logs, infection control monitoring. Reviews and monitors reports for the identification and trending of deficiencies. Provides oversight for the Employee/Volunteer TB and flu program. Serves as the Compliance Officer for the agency. Chair of Safety Committee.
Primary Department: Administration
Reporting Relationship: Director of Patient Care Services (DPCS)
Position Type: Exempt, Full Time, Benefitted 0.8 Status
Salary Grade: # 13
Job Details and Essential Functions:
- Coordinates and participates in Quality Assurance and Performance Improvement (QAPI) program and Hospice sponsored in-services and annual competencies
- The Compliance Officer assumes responsibility for designing, and evaluating compliance program.
- Performs quality audits of the medical records and medical record system; verifying accurate and complete documentation
- Consults with DPCS to ensure continuity of processes and policies and overall quality of patient care services, as required by the COPs
- Participates in development and implementation of written policies and procedures to improve the quality, efficiency and consistency of patient care
- Assists in the monitoring of QAPI activities of the staff
- Assists with the surveillance reporting requirements for Infection Control Management, including oversight for the Employee/Volunteer TB and Flu program.
- Shares administrative on-call duties
- Responsible for supporting and helping to ensure a safe environment for patients/families, and a safe working environment for self and co-workers
- Serves as the Compliance Officer for the agency, appointed by the Board of Directors.
- Providing accurate and timely records of critical events
- Provides other duties as assigned by the DPCS
Knowledge and Skills
- Empathetic with an ability to work in a dynamic, rapidly changing environment
- Excellent listening, verbal, and written communication skills
- Ability to follow written directions and to provide accurate and timely documentation.
- Ability to work as a member of an interdisciplinary team
- Assists with establishing a culture within HOF that promotes quality of care, prevention, identification, and resolution of instances of conduct that do not conform to Federal and State law and Federal, State and private payer health care program requirements as well as HOF policies and procedures.
- Maintains and utilizes in depth knowledge of Medicare Conditions of Participation, California Health & Safety Code, Title 22 and California Hospice Quality Standards.
- Effectively articulates and demonstrates HOF’s commitment to ethical practices.
- Through education implements the quality indicators to improve HOF’s efficacy and quality of services.
- Demonstrated competence in Hospice care delivery techniques, with willingness to learn ‘Most Current’ Hospice nursing competencies and procedures
- Dedication to 'Nursing Practices Act' record keeping requirements
- Intolerant of conditions that are symptomatic of neglect or abuse
- Sensitivity to and ability to interact with various racial, religious, and ethnic cultures in the organization service area
- Computer savvy with software programs such as EMR, Outlook, etc
- Follow written and verbal directions while retaining the ability to tactfully question directions that seem unclear, unsafe, or illegal
Education & Experience
- Three plus years’ experience as a RN or one year experience as a RN in QAPI in a healthcare setting.
- Five years’ experience as a RN or two years’ experience in a healthcare setting
- BSN Degree with Public Health Certificate
License / Certifications
- Possess and maintain current California RN license
- Possess and maintain current CPR certificate
- Possess and maintain valid California driver’s license, a reliable automobile and evidence of appropriate liability insurance
- Certified Professional in Healthcare Quality (CPHQ)
- Certified Hospice and Palliative Nurse (CHPN)
Job Type: Full-time
- Registered Nursing: 3 years (Required)
- RN in QAPI in Healthcare setting: 1 year (Required)
- Paid time off
- Parental leave
- Health insurance
- Dental insurance
- Healthcare spending or reimbursement accounts such as HSAs or FSAs
- Other types of insurance
- Retirement benefits or accounts
- Employee discounts
- Workplace perks such as food/coffee and flexible work schedules
- Commuting/travel assistance