Bayside Terrace is a Specialized Mental Health Rehabilitation Facility (SMHRF) located in Waukegan, Illinois. We are a therapeutic facility accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). Bayside Terrace's mission is dedicated to providing accessible, safe, efficient and effective psychiatric rehabilitation services to individuals with chronic and persistent mental illness. We hope that you will join us in the feeling of pride as we work to help our residents who have a great need for the services that Bayside Terrace offers.

ESSENTIAL DUTIES:

1. Ensure that correspondence is conveniently received and reasonably accessible for all residents.

2. Ensure that residents may privately meet with visitors at any reasonable hour unless visits are restricted due to the treatment plan of the resident.

3. Provide space for visits which allows facility personnel to reasonably announce their intent to enter, except in an emergency, before entering any resident's room during visits.

4. Ensure arrangements are made for a resident's attendance at religious services of their choice, at the resident's expense.

5. Ensure no religious beliefs or practices or attendance at religious services may be imposed upon any resident. (Section 3-109 of the Specialized Mental Health Rehabilitation Facilities (SMHRF) Code).

6. Provide a policy and procedure for staff to follow when it is necessary to refuse access to the facility of any person if the presence of that person in the facility would be injurious to the health and safety of a resident or would threaten the security of the property of a resident or the facility, or if the person seeks access to the facility for commercial purposes.

7. Provide all residents, or their representatives, with the name, address, and telephone number of the appropriate State governmental office where complaints may be lodged. (Section 3-112 of the SMHRF Code).

8. Guarantee no resident shall be subjected to unlawful discrimination as defined in Section 1-103 of the Illinois Human Rights Act by any owner, licensee, executive director, employee, or agent of a facility.

9. Establish a Residents' Advisory Council consisting of at least five residents chosen by residents.

a. Designate a member of the facility staff other than the Executive Director to coordinate the establishment of, and render assistance to, The Council.

b. Ensure no employee or affiliate of the facility is a member of The Council.

c. Ensure the Council meets at least once each month with the staff coordinator.

d. Ensure the appointed staff member aids The Council in preparing and disseminating a report of each meeting to all residents, the Executive Director, and the staff.

e. Ensure records of council meetings shall be maintained in the office of the Executive Director, subject to compliance with the Health Insurance Portability and Accountability Act and Mental Health and Developmental Disabilities Confidentiality Act.

f. Ensure the Residents' advisory Council can communicate to the Executive Director the opinions and concerns of the residents.

g. Ensure the council can review procedures for implementing resident rights and facility responsibilities and make recommendations for changes or additions that will strengthen the facility's policies and procedures as they affect resident rights and facility responsibilities.

10. Provide the ability for residents to be free leave at any time.

11. Delegate, in writing, authority to a qualified subordinate to act during the Executive Director's absence.

a. This administrative assignment shall not interfere with resident care and supervision. The Executive Director, or the person designated by the Executive Director to oversee the facility in the executive director's absence, is the agent of the licensee for the SMHRF Code.

b. Arrange for facility supervisory personnel to annually attend appropriate educational programs.

c. Appoint, in writing, a member of the facility staff to coordinate the establishment of, and render assistance to, the Residents' Advisory Council.

12. Provide opportunities for employees and consultants to be familiar with the SMHRF Code and the codes and shall be responsible for ensuring that the applicable requirements are met in the facility, and that employees are familiar with the requirements of the SMHRF Code and relevant to their job duties.

13. Implements and maintains a data-driven quality assessment and performance improvement (QAPI) program.

a. Ensure the program emphasizes quality structures, processes and activities, with a goal of improved behavioral health outcomes that enable residents to transition to the most integrated community-based settings possible.

b. Ensure the written program is updated annually and includes the following:

i. Ensure there is an ongoing program for quality improvement and resident safety as a priority for facility management that is communicated throughout the facility;

ii. Ensure there is a quality improvement committee that shall regularly review and evaluate all QAPI activities and progress;

iii. Ensure all levels of service in the facility, the priorities for improved quality of care and resident safety are identified and addressed, and all improvement actions are evaluated for efficacy;

iv. Ensure benchmarks, targets and standards of care for safety and quality of care that, for each indicator, are well established and communicated throughout the facility. Ensure outcomes are regularly reviewed to measure them against the benchmarks and targets;

v. Ensure the allocation of adequate resources for measuring, assessing, improving and sustaining the facility's performance complying with the SMHRF Code;

c. A method for investigating, monitoring and tracking incidents and accidents, with a written action plan to prevent reoccurrences;

d. Ensure that the facility shares the results of the QAPI activities, data collections and performance improvement projects (PIPs) with board members of Resident Council. Ensure input and recommendations from Resident Council shall be shared with the governing body;

e. Implement a method for conducting annual PIPs, with the report of the PIP and recommendations for process improvements.

f. Ensure the data collection and reporting process assures the submission, at least quarterly, of all reports or other required data within prescribed time frames.

g. Verify that prior-authorizations and re-authorizations are secured as applicable for appropriate care and service delivery;

h. Verify that assessments and treatment plans have been conducted to meet resident needs;

i. Verify that evidence-based practices and person-centered treatment plans are being performed to meet resident needs as applicable;

j. Verify that appropriate licensed and certified IDT professionals are performing duties as required;

k. Verify that planning and community linkage has occurred to facilitate resident-community integration;

l. Verify that care coordination and case management systems are in place to achieve quality treatment outcomes and community integration;

m. Verify that facility policy and procedures are established, documented, implemented and evaluated;

n. Verify that resident records contain all relevant information, including, but not limited to, demographic information, historical information, medical information, nutrition and dietary information, social information, psycho-social information, treatment plans, therapy information, assessments, discharge plans, and community support services;

o. Verify training to the administration, to the supervisory staff, and to the direct care staff.

14. Ensure the Quality Improvement Committee shall:

a. Review all performance indicators, data from resident quality of life surveys, staff surveys, findings from root cause analyses, performance improvement projects, and other relevant sources of data. The quality improvement committee shall make recommendations to the facility leadership and governing body based on the facility's performance of the indicators in subsection.

b. The quality improvement committee shall be composed of members of the facility management team. Procedures for the operation of the quality improvement committee shall be included in the written QAPI program plan;

c. Conduct a root cause analysis when an in-depth understanding is needed of an incident or accident, or a violation, in the facility, including its causes and implications.

15. Oversee the Risk Management and Quality Improvement Committee’s development of policies and procedures for the use of root cause analyses to examine issues across systems in the facility to prevent future serious incidents and accidents and violations, and to promote sustained improvement.

16. Ensure the findings of root cause analyses are available to the Department, DHS-DMH and the Department of Healthcare and Family Services upon request.

17. Secure all service providers, including licensee, Executive Director, employee, or agent of a facility, shall not abuse or neglect a resident.

18. It is the duty of any facility employee or agent who becomes aware of abuse or neglect of a resident to report it immediately to the Executive Director and to the Department, but no later than within 24 hours after becoming aware of it.

19. Facilities shall comply with Section 3-610 and 3-810 of the Nursing Home Care Act.

20. With respect to theft or misappropriation of a resident's property, and to whistleblower protection, the provisions under Section 3-610 and 3-810 of the Nursing Home Care Act shall apply to employees of facilities licensed under the SMHRF Code. (Section 3-107 of the SMHRF Code)

21. Upon awareness of the abuse or neglect of a resident or theft of a resident's property, immediately report the matter by telephone and in writing to the resident's guardian, the resident's substitute decision maker, if any, or any other individual designated in writing by the resident, and to The Department, but no later than within 24 hours after becoming aware of the abuse, neglect or theft.

22. Safeguard residents from being subjected to verbal or physical abuse of any kind. Corporal punishment of residents is prohibited. The facility shall not permit residents to discipline other residents. The facility shall comply with this Section and with Section 380.550 in every instance of assault or battery by a resident of another resident or of an employee.

23. Ensure any facility employee or agent who becomes aware of another facility employee's or agent's theft or misappropriation of a resident's property shall immediately report the matter to the Executive Director. An Executive Director who becomes aware of a facility employee's or agent's theft or misappropriation of a resident's property shall immediately report the matter by telephone and in writing to the resident's representative, the Department, and the local law enforcement agency.

24. Ensure resident allegations of abuse shall be reported to the Department within 24 hours after the allegation is made, and the facility shall comply with the reporting requirements of Section 380.550. A full investigation report shall be filed with the Department within seven days after the incident occurred.

25. When an investigation of a report of suspected abuse of a resident indicates that an employee of the facility is the perpetrator of the abuse, that employee shall immediately be barred from any further contact with any resident in the facility, pending the outcome of any further investigation, prosecution or disciplinary action against the employee.

26. When an investigation of a report of suspected abuse of a resident indicates that another resident residing in the facility is the perpetrator of the abuse, the perpetrator's condition shall be immediately evaluated to determine the most suitable therapy and placement for that person, considering the safety of that person as well as the safety of other residents and of employees of and visitors to the facility.

27. Safeguard the provisions of the Whistleblower Act applies to employees of the facility licensed under the SMHRF Code.

28. Upon the occurrence of any disaster requiring hospital service, police, fire department or coroner, the executive director or designee shall provide a preliminary report to the Department.

29. Research: No resident shall be subjected to research or treatment without first obtaining his or her informed, written consent. The conduct of any experimental research or treatment shall be authorized and monitored by an institutional review board appointed by the executive director. No person who has received compensation in the prior 3 years from an entity that manufactures, distributes or sells pharmaceuticals, biologics, or medical devices may serve on the institutional review board.

30. Responsible to safeguard residents from research or treatment to be conducted on a resident or give access to any person or person's records for a retrospective study without the prior written approval of the institutional review board.

31. No Executive Director, or person licensed by the State to provide medical care or treatment to any person, may assist or participate in any experimental research on or treatment of a resident, including a retrospective study that does not have the prior written approval. This conduct shall be grounds for professional discipline by the Department of Financial and Professional Regulation.

32. Responsible to verify a physician's credentials by contacting a hospital through which the doctor has practicing rights and by checking applicable databases, including, but not limited to, the Illinois Department of Financial and Professional Regulation License Lookup and the National Practitioner Data Bank.

33. Responsible for planning, organizing, staffing, directing, and coordinating of and implementation of federal, state, and local laws and regulations applicable to the facility and residents, personnel, and physical plant.

34. Responsible for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures.

35. Responsible for the facility environment on a twenty-four-hour basis, seven days a week.

36. Must always be available for emergency or must delegate a responsible person to receive and act in emergency situations when he or she is not available.

37. Administers, directs, and coordinates all activities of Bayside Terrace to carry out the Philosophy and Objectives of the facility as to the care of residents of the SMHRF.

38. Promotes favorable public relations.

39. Coordinates departmental activities of Bayside Terrace, LLC.

40. Promotes effective communications with medical personnel, employees, residents, resident family members/friends and the public.

41. Recommends and helps develop policies and procedures for all facility departments.

42. Supervises Department Heads and Administrative Staff; meets with Department Heads and makes rounds.

43. Evaluates employee performance, yearly, under advice of employee supervisors.

44. Reviews and evaluates reports from the facility’s committees and consultants, and documents disposition and implementation of recommendations.

45. Ensure volunteer program is planned and supervised by a designated employee.

46. Prepare and forward reports to authorities as required by federal, state, and local agencies and management.

LEVEL OF EDUCATION/QUALIFICATIONS/REQUIRED CERTIFICATION/LICENSE:

1. The Executive Director shall meet the requirements in Section 380.430 as follows:

a. An LPHA or QMHP with a minimum of at least two years of supervisory or management experience and at least one year of relevant experience, e.g., working directly with persons with serious mental illness; or

b. An administrator licensed under the Nursing Home Administrators Licensing and Disciplinary Act, with a minimum of at least two years of supervisory or management experience and at least one year of experience working directly with persons with serious mental illness; or

c. At the end of the three-year provisional license period, nursing home administrators who were acting as executive directors of a specialized mental health rehabilitation facility as of July 22, 2013, and who had a minimum of at least two years of supervisory or management experience and at least one year of experience working directly with persons with serious mental illness may serve as executive director of a facility licensed under the Act.

i. After the provisional licensing period has ended, all newly hired executive directors of specialized mental health rehabilitation facilities shall meet the requirements listed in (a).

Additional Compensation:

• Bonuses

Benefits:

• Health insurance
• Dental insurance

This Company Describes Its Culture as:

• Detail-oriented -- quality and precision-focused
• Innovative -- innovative and risk-taking
• Aggressive -- competitive and growth-oriented
• Outcome-oriented -- results-focused with strong performance culture
• Stable -- traditional, stable, strong processes
• People-oriented -- supportive and fairness-focused
• Team-oriented -- cooperative and collaborative

Schedule:

• Monday to Friday
• Weekends required
• Holidays required
• Day shift
• Night shift
• Overtime
• 8 hour shift
• On call
• Overnight shift
• Other

Work Remotely

• No

Job Type: Full-time

Experience:

• Nursing Home Administrator: 1 year (Preferred)

Education:

• Bachelor's (Preferred)

License:

• Licensed Nursing Home Administrator (Required)

Work authorization:

• United States (Required)

Work Location: In person