QAPI and Regulatory Compliance RN

Job Description Summary

The QAPI and Regulatory Compliance RN is responsible for QAPI process for assigned agencies. The QAPI and Regulatory Compliance RN is responsible for ensuring that assigned offices are complying with the Community Health Accreditation Partner (CHAP) standards Center for Medicare and Medicaid Services (CMS) conditions of participation and other regulatory licensures requirements.

Essential Job Functions/Responsibilities

1. Review documentation to identify areas which may have fallen out of compliance and communicates findings and recommendations to Clinical Manager and hospice personnel.

2. Tracks and trends information for QAPI (Quality Assurance Performance Improvement)

3. Develops Plan of Correction and/or PIP (performance improvement plan) to bring area to compliance.

4. Performs chart audits as a written into plan of correction and/or PIP.

5. Provides education to bring identified areas into compliance.

6. Visits offices as directed to observe for regulatory compliance.

7. Assists Regional Director of Compliance and Survey Readiness/Compliance Officer to identify areas of risk and develop plan to bring into compliance.

8. Provides education about the QAPI program.

9. Prepares and leads quarterly QAPI meetings for each assigned agency.

10. Assists with policy maintenance and revisions as assigned.

11. Provides education guidance and assistance on the Emergency Preparedness Program to agency leadership.

12. Assists with committees meetings and team projects relevant to regulatory compliance as well as department/intradepartment problemsolving.

13. Assists in the orientation of new employees.

14. Demonstrates understanding of HIPAA requirements with respect to contract reviews Information related policies and operations for the organization.

15. Assists Regional Director of Clinical Operations and other supervisory hospice personnel in the planning implementation and evaluation of inservice and continuing education programs.

16. Assists agency leadership which may include but not limited to preparing for survey staff orientation and education assisting with office clinical operations conducting patient visits assisting in covering On Call as requested.

17. Complies with accepted professional standards and principles.

18. Assesses learning needs of all hospice personnel. Plans and provides education in conjunction with Regional Director of Clinical Operations and other hospice leadership.

19. Assists in developing and writing processes.

20. Assists on other projects and committees.

21. Travel to various assigned agencies. The amount of travel and length of travel will vary by agency need.

22. Performs other duties and activities as delegated by the Regional Director of Compliance and Survey Readiness/Compliance Officer.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform jobrelated tasks other than those stated in this description.

Position Qualifications

Registered nurse with current licensure to practice professional nursing in the state.

Willing to pursue licensure in all states Moments Hospice operates within.

Graduate of accredited school of nursing.

Previous experience in hospice setting. Proven ability to work within an interdisciplinary setting.

Familiar with Hospice regulations.

Complies with accepted professional standards and practice.

Understands hospice philosophy and issues of death/dying.

Understands principles of pain/symptom management.

Complies and maintains current CPR certification.

Demonstrates excellent observation verbal and written communication skills.

Ability to Travel up to 100 of the time.

Understanding of the hospice QAPI process.

Attention to detail