Director of Quality and ComplianceThe Director of Quality and Compliance strives to ensure that all Agency personnel adhere to regulatory requirements, including but not limited to the Federal Conditions of Participation (COPs), New York State Department of Health Regulations outlined in NYCRR 10 section 763, Medicare and Medicaid billing rules and other governmental oversight and that services provided meet the highest quality standards. This position also performs a variety of other duties including oversight of patient rights and patient confidentiality and privacy standards; patient satisfaction surveying; infection control and risk management; policy and procedure development and maintenance; compliance with licensing, and health monitoring and mandatory facility education requirements; emergency management; and performance improvement.Duties and ResponsibilitiesDevelopment, implementation, and evaluation of the Agency’s Quality Assessment Performance Improvement Program (QAPI).Development, implementation, and evaluation of the Agency’s Corporate Compliance Program. Serves as the Agency’s Compliance Officer. Ensure effective staff training and monitoring of problem prone areas of compliance.Development, implementation, and evaluation of the Agency’s Emergency Management Program. Ensures effective staff training; ensures drills are performed including completion of after action reports; and ensures completion of the annual Hazard Vulnerability Assessment (HVA). Development, review and revision of Agency policies and procedures to ensure alignment with regulatory requirements. Maintains the policy and procedure manual. Provides guidance to all staff on Agency policy. Development, implementation, and evaluation of the Agency’s program related to patient privacy and confidentiality to meet all federal Office of Civil Rights Health Insurance Portability Accountability Act (HIPAA) regulations. Serves as the Agency’s Privacy Officer. Participates in all external auditing including but not limited to NYS DOH surveys, and Medicare and Medicaid auditing. Develops and ensures implementation of plans of correction and ensures that responses to all auditing are timely. Maintains records of auditing.Oversight of complaint resolution. Ensures timely follow-up and documentation. Maintains the Agency’s complaint log per DOH requirements.Oversight of services provided through outside vendors. Reviews all vendor documents to ensure compliance with regulatory requirements prior to contracting. Ensures all contracts meet regulatory requirements and Agency policy.Monitors Agency quality measures related to OASIS and claims-based outcomes and HHCAHPS. Maintains accounts on iqies and HHCAHPS sites to obtain quality data. Oversight of Medicare Expedited appeals and conventional Medicare appeals process. Maintains records of all appeals. Serves as the Agency’s contact with the Medicare QIO.Oversight of risk management, including documentation and maintenance of patient and staff incident reporting. Serves as liaison with Agency attorneys related to legal action. Oversight of patient medical record release to ensure compliance with HIPAA regulations according to minimum necessary rules.Oversight of quarterly utilization review and other record auditing related to regulatory requirements, performance improvement, plans of correction and other focused reviews. Development of training programs related to the COPs/DOH regulatory requirements, QAPI, Corporate Compliance, HIPAA, and Emergency Management. Participates in orientation and annual mandatory inservice development and implementation. Serves as the Agency’s coordinator on NYS Health Commerce System. Responds to DOH HERDS reports when required.Maintains relationship with the Home Care Association of NYS. Keeps abreast of information from NYS DOH, CMS, NGS, OCR, OIG, OMIG and shares information with Agency leadership.Works with the Agency’s VP of Clinical Operations and Staff Development to develop the orientation and educational programs to meet regulatory requirements. Works with Human Resources to understand regulatory requirements as they pertain to personnel. Supervises the Quality Management Clinical Analyst and the Quality Management Assistant. In collaboration with each department, provides the appropriate guidance to ensure adherence to regulatory requirements. Other job duties as assigned.Committee Responsibilities:Quarterly Professional Advisory CommitteeQuarterly Corporate Compliance CommitteeAnnual and ad hoc Emergency Management Team Job Qualifications RequiredNew York RN licensure Minimum two years home care experience in a Certified Home Health AgencyMinimum one year experience with quality management preferred.Knowledge of applicable federal and state laws and regulationsAbility to write reports, policy, and other correspondence. Ability to work with and through people to establish goals, objectives, and action plans.Knowledge of technology to track and streamline data.Ability to interpret statistical information and to create statistical displays.Knowledge of change managementEducation, Knowledge, Skills and Abilities PreferredEducation leading to RN licensure, preferably BSN.Master's Degree preferred.Federal Conditions of Participation for Home Health CareNYS DOH regulations for Home CareOASISHHCAHPSWord, Excel, Power Point