Hospice of San Joaquin is the oldest not-for-profit hospice, with over 46 years. We serve all of San Joaquin and Stanislaus Counties. We are committed to continuing to be the leader in ensuring the quality of the journey, from a serious illness to the end of life, and to honoring our mission by honoring life and ensuring patients and their Caregivers are the focus of everything we do. We seek a Dynamic, self-motivated Director of Compliance and Education who thrives in a fast-paced environment and supports our mission.
The Director of Compliance and Education (DCE) is responsible for overseeing the administration and implementation of the Compliance Program for Hospice of San Joaquin. The DCE shall report quarterly to the QAPI Committee on the operation and findings of the Legal Compliance Program. As such, the DCE will have broad autonomy to review all aspects of Hospice of San Joaquin’s billing, charting, and other Agency areas as the DCE deems appropriate to determine the level of Hospice of San Joaquin’s Compliance Program. The DCE shall report to the CCO regarding all day-to-day personnel issues, but to the Board of Directors for Compliance Complaints and investigations. The DCE should seek advice from legal counsel when appropriate.
The Director of Compliance and Education provides training and education to Hospice of San Joaquin clinicians, as well as the clinical staff of our community partners, to foster an understanding of end-of-life care. The Hospice Educator will also support Nursing Leadership and the Chief Clinical Officer in developing and monitoring clinical quality standards that align with Hospice conditions of payment and participation.
ESSENTIAL DUTIES AND RESPONSIBILITIES FOR THE DIRECTOR OF COMPLIANCE AND EDUCATION (DCE)
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Facilitates chart audits every quarter utilizing the Hospice Clinical Record Audit Tool by the Joint Commission.
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Works collaboratively with nursing supervisors to ensure documentation is complete and consistent with care and reflects legal requirements. Performs Clinical on-site visits to audit adherence to Conditions of Participation as needed.
- Assists with investigations and tracks serious adverse events/incident/unusual occurrences, develops corrective action plans in conjunction with the CEO and CCO, and reports as appropriate to outside agencies.
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Member of the Patient Grievance Committee (QAPI Committee) collaborates with management staff in follow-up of concerns expressed by patients, families, and physicians.
EDUCATION: Designs and implements the staff education program, ensuring all compliance items are met. Collaborates with Chief Clinical Officer to provide a process to promote and ensure employee orientation, competency (skills lab), and in-service education programs. Ensures that these programs remain updated to changes in regulations, and in response to employee surveys, CAHPS scores, and PIP’s.
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In collaboration with the Compliance and Chief Clinical Officer or designee, serves as a resource to Clinical Managers in the training and development of hospice clinicians (RN, LVN, SW, Chaplain and HHA):
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Develops and coordinates a comprehensive nursing orientation program.
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Oversees development and ongoing use of HSJ’s simulation lab to train clinical staff on established visit/patient care models.
- In collaboration with the Chief Clinical Officer and Nursing leadership, supports ongoing clinical quality efforts, including:
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Identifies and develops clinical documentation and patient care standards in alignment with state/federal regulations and best-known practice.
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Provides training to clinicians on documentation/patient care standards
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Monitors the quality of clinical documentation/patient care via regular audits
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Collaborates with clinical supervisors in providing focused training activities to address identified performance improvement opportunities
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Develops, coordinates, and presents continuing educational/certification programs to Hospice clinicians.
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Assists in the identification of skills for annual competency and provides in-service training support.
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Ensures HHA/CNA are compliant with State CEU requirements.
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Maintains the agency CEU Licensing program. Coordinates with CCO and Medical Director to provide two (2) CEU courses a year.
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Monitors the performance of the program under the guidance of the CCO/QAPI Coordinator, continually taking appropriate steps, as directed, to improve patient care and promote increased patient satisfaction and quality
- Displays proficiency in the utilization of the company’s Electronic Medical Record (EMR), assists in EMR training, and also acts as an EMR resource for program staff.
- Serves as a CPR Instructor and assists with maintaining annual compliance with federal and state requirements.
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Provides training to clinicians within the community on end-of-life and Hospice-specific clinical issues.
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Develops, coordinates, and presents in-service training in SNFs, RCFEs, and medical offices.
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Coordinates Hospice of San Joaquin involvement in providing hospice/palliative care training experiences to nursing students, as well as other local RN/NP/MD Students/residents.
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Participates in Quality Assurance Performance Improvement (QAPI) committee meetings as needed
- Assists leadership in the development of Performance Improvement Plans (PIPs) to ensure that education related to high-risk problem-prone areas is provided to address identified deficiencies
- Provides ongoing education to All Staff related to Mandatory Annual Education requirements through in-services and other forms of education; in-person or online using the agency’s Learning System
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Performs ongoing audits of clinical charts, patient eligibility, pre-bill audits, and other internal audits, as directed, that measure regulatory, clinical compliance, and skills as requested.
Direct Patient Care – as needed
The Hospice Educator may, from time to time, provide direct nursing care including, but not limited to, the following:
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Actively participating in coordination of all aspects of the patient’s care, in accordance with current professional standards and practice.
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Participating in admission, discharge planning, and ongoing patient assessments.
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Developing, evaluating, and adjusting the patient’s Plan of Care (POC) as indicated; consults Clinical Manager before major changes in patient’s POC.
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Contributing to patient and family counseling and education and providing support to patients/families regarding patient care services.
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Collaborating with physicians and staff regarding patients’ changing condition.
COMPLIANCE: As Compliance Officer, assures compliance plan includes all elements, compliance line is available for staff and patient reporting, and investigates issues. Monitors organization compliance with regulatory and accreditation standards.
ACCREDITATION/JOINT COMMISSION SURVEY:
- Understand the regulations and requirements for State, the Joint Commission, and Kaiser certification/licensure. Leads preparation of agency for The Joint Commission accreditation, California Department of Public Health surveys, and annual Kaiser site visits.
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Acts as liaison with the surveyor and assures that the surveyor has the needed staff (managers) for the interviews and the needed documentation.
- Assures plan of correction is completed and submitted promptly to the surveying authority after approval of the CCO and CEO.
LEADERSHIP:
- Promote self-growth and collegial relationships with others in the home care industry.
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Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal and professional networks, and participating in professional organizations or societies.
SUPERVISION
Supervises Medical Records Department.
Assures that direct report employees are fulfilling agency expectations (job duties), state, federal, and The Joint Commission requirements.
The above statements are only meant to be a representative summary of the major duties.
JOB QUALIFICATIONS
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Current RN, BSN license
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Five years Hospice experience
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Reliable transportation including valid California driver’s license, proof of active auto insurance and acceptable driving record.
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Ability to meet the job’s physical demands (i.e., kneeling, squatting, bending, lifting.
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Knowledge/experience using any EMR (Electronic medical Records) system is recommended.
- CPR Training
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Vehicle – Ability and willingness to drive own vehicle, have a valid California driver’s license and have automobile insurance, which meets State standards. All employee’s volunteers, consultants and consultant volunteers who drive need to provide Hospice of San Joaquin evidence of insurance. This is necessary to be covered by the agency’s non-owned auto policy.
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Mobility – Frequent operation of a keyboard and sitting for long periods of time; occasional standing for long periods of time, walking, pushing/pulling, bending/squatting, driving, climbing ladders or stairs and crawling.
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Frequency of Lifting – Occasional lifting of 5 to 35 lbs.
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Visual Requirements – Constant use of overall vision; frequent need for color perception, hand/eye coordination, reading/close-up work, and field of vision.
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Hearing/Talking – Frequent hearing of normal speech, hearing the telephone, talking in person and on the telephone; occasional hearing of faint sounds.
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Emotional/Physiological Factors – Frequent public contact, decision making, concentration and working alone; occasional exposure to emergencies (including death), heights and hazardous materials.
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Ability to participate in the evaluation(s) of own performance by identifying strengths and weaknesses and by developing a plan to improve areas of weakness.
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Environmental Conditions – Occasional exposure to noise, dirt, dust, smoke, fumes, poor ventilation, and cold and heat.
PRE-EMPLOYMENT REQUIREMENTS:
1. Health Screening
2. Background Check
3. Reference Check
4. Drug Screening
5. Immunization records – part of the terms and conditions of employment.
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Competitive hospice industry compensation
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Benefits package with multiple plan offerings and generous employer contribution
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401(k) Retirement plan with employer match
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AFLAC insurance plans
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Flexible Spending Account (FSA)
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Fitness Center membership discount
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Employee Assistance Programs (ESP)
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Supportive work culture which encourages work-life balance
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Paid Time Off (PTO)
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Monthly mileage reimbursement
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Employee Referral Program
If you are interested in being part of a dynamic team and helping us continue to be the leader in ensuring the quality of the journey, from a serious illness through end of life, and to honor our mission by honoring life by ensuring patients and their Caregivers are the focus of everything we do, we encourage you to apply. To learn more about Hospice of San Joaquin, please visit our website at: www.hospiceofsanjoaquin.org
