AK - Quality Management and Accreditation - LTC QAPI

Primary responsibilities are as the Long-Term Care (LTC) QAPI Coordinator / RN. The primary purpose of this position is to facilitate conduct coordinate and evaluate consistent quality clinical care delivery through adopted clinical standards policies practices protocols and processes. Ensure compliance with CMS and other regulatory bodies as applicable. This position coordinates regulatory surveys; continuous accreditation readiness activities. As a member of the LTC facility interdisciplinary team this position also coordinates assigns performs and evaluates general practices within the facility as it relates to safety regulatory compliance corporate standards and more using the QAPI program as one method of monitoring. Infection Control facilitation as it relates to adopted and expected performance is aligned with this position. This position works closely with Administration Providers Leaders and Staff to ensure awareness of quality and patient safety and to facilitate improvement efforts in all areas. Key Essential Functions and Accountabilities of the Job May include any and/or all of the below: Collaboration with the Long-Term Care Administrator on overall QAPI objectives for the organization. Plan organize and direct quality assurance program and activities. Lead projects and provide education and coaching and coordinate with directors/managers to ensure QAPI efforts are integrated into all operations and departments including staff responsibilities. Provide ongoing assessment of performance analyzes clinical outcome data and identifies performance improvement opportunities or trends. Plan develop organize implement coordinate and direct the quality assurance and assessment program designed to enhance the quality of resident care in accordance with current rules regulations and guidelines that govern nursing care facilities. Establish and maintain tracking systems for recommendations of groups involved in quality assurance. Develop and implement appropriate plans of action to correct identified deficiencies. Assist in developing follow-up procedures for monitoring identified problem areas. In collaboration with the Risk Manager perform RCA as necessary and keep all records of FRIs (facility reported incidents) and Datix events and assist in investigations of incident reports complaints resident care issues and others as requested. Make written and oral reports and recommendations to the Administrator as necessary or required concerning the operation of the quality assessment and assurance program. Design a process for and conduct an evaluation of QAPI efforts (at least annually). Facilitate a discussion within the quality committee for this annual review. Develop and maintain formal QAPI plan. Organize and facilitate the quality committee meetings by guiding discussion around performance measures and prioritizing and developing quality efforts and maintaining meeting minutes. Participate in Facilitys surveys. Review and write/revise policies and procedures survey reports facility wide assessment etc. Communicates professionally and effectively with all levels of the organization; serves as a resource mentor and role model for others as QM is continuously integrated into everyday processes within the organization. Support the QMA Department with quality management responsibilities to include but not limited to; chart audits rounding accreditation readiness and support participate and facilitate quality committees as applicable. Other duties as assigned including cross coverage of other QM Team member roles. Education Certifications and Licenses Required Current full unrestricted active Registered Nursing license in Hire must have applied for an Alaska nursing license before the start staff must have an active Alaska license. Certified Professional in Healthcare Quality (CPHQ) or QAPI Certified Professional (QCP) or other LTC Quality Certification obtained within 3 years - required. Experience Required 2 years experience monitoring quality and regulatory requirements planning and coordinating process changes. Demonstrated experience that shows leadership skills in facilitating and leading cross-functional teams and in working collaboratively with groups or teams. Preferred: experience working in Long Term Care

Shift: Full Time Days

Specialty Type: Nursing

Sub Specialties: General Practice

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