Quality Improvement Coord

POSITION SUMMARY: The Quality Improvement (QI) Coordinator implements a comprehensive quality improvement plan that ensures all Adult Intellectual and/or Developmental Disabilities (IDD) programs remain in compliance and provide quality services by conducting internal evaluations to meet all regulatory and health and safety standards and best practices; provides regulatory guidance and expertise to programs; develops, implements, and trains on policies based on quality best practices. This position provides regulatory oversight to the Intermediate Care Facilities (ICF), Community Residential Services (CRS), Adult Day/Work Services, Life Sharing, and In-Home Supports Programs.

DUTIES AND RESPONSIBILITIES:

• Conduct internal evaluations as part of the Adult Intellectual and/or Developmental Disability (IDD) Programs Continuous Quality Improvement (CQI) program with tasks that may include but are not limited to completing, collecting, and analyzing audit and other data such as chart audits, medication audits, meal audits, environmental and vehicle audits in adherence to the Office of Developmental Programs (ODP) quality management principles
• Review findings with program leadership, recommending possible programmatic changes, additional trainings, and providing just-in-time training during audit where possible
• Provide analyses of status of the program for reporting Key Performance Indicators (KPIs) on a monthly or quarterly basis to evaluate effectiveness of programs as part of the greater organizational assessment
• Complete satisfaction survey reviews, analyzing and reporting on the data for continuous improvement of operations
• Assist in preparation for external audits, reviews, inspection, and act as point person, if needed, by corresponding with auditing/oversight bodies and providing of required documentation and information during surveys, either virtually and/or in person
• Lead the process with operations to develop a Plan of Correction (POC) in response to formal audits completed, external audits completed by funders, and informal observations in order to prevent problems or concerns from reoccurring within the operations of the program relative to safety, compliance, and quality services
• Oversee implementation of POC as assigned by the Director of Quality Improvement including but not limited to:
  
  
  
  • Surveying data, actions, and processes after submission of a POC
  • Reporting POC compliance to program leadership and Director of QI
  • Assisting in developing training and implementation plans as needed to meet plans of correction
  
  
  
  
• Initiate QI and Quality Assurance (QA) projects to aid in Elwyn's on-going commitment to the delivery of exceptional services, which may include but not be limited to, walkthroughs in residential buildings; participation in staff training; and questioning current processes and developing Standard Operating Procedures (SOPs) with the program leadership to improve quality of services provided
• Participate in the development of policies and procedures, utilization reviews, facility safety, and fire safety to ensure well-being of all program participants, family members, and staff members
• Attend committees and sub-committees as assigned to help develop improved processes of service delivery
• Report QI needs to the Director of QI to ensure transparency and follow up with program leadership where needed
• Anticipate future needs or problem areas by auditing trends and data analysis and suggest effective action including but not limited to trainings for Qualified Intellectual Disabilities Professionals (QIDPs), supervisors, directors, and Direct Support Professionals (DSPs) to ensure quality of services is always the focus
• Audit the IDD program for evidence of active treatment based on the program's regulatory standards by reviewing program documentation (e.g. Individual Program Plans (IPP), Quarterly Reviews, Skills Assessments, Data Collection Cards, Data Collection Audits, etc.) to ensure everything aligns appropriately and will pass an external audit
• Conduct and evaluate chart audits and share the results with program operations and QI leadership to inform internal stakeholders of accuracy and timeliness of information found in the documents, such as medical care, and completeness of documentation including assessments, annuals, quarterlies, etc. having been completed and make suggestions for improvement
• Conduct interviews with individuals supported, their families, staff members, advocates, etc. to verify quality services are being delivered
• Evaluate all aspects of programming, including but not limited to observations of residences and activities in progress, medication observations, etc. to be able to provide immediate feedback to DSPs and other personnel at the site, and to ensure all policies and procedures are followed and enforced
• Provide in-service trainings, including but not limited to:
  
  
  
  • Qualified Intellectual Disabilities Professional (QIDP)/Program Specialist (PS) training
  • Revisions or new corporate policies
  • New protocols they developed in response to audit findings to support compliance
  • Program developments
  • Applicable regulations
  
  
  
  
• Provide resource information to program staff for all questions regarding forms, policies, and protocols regarding the individual's annual program plan writing, implementation, revision, and training
• Maintain a current file of all regulatory standards including 2380, 2390, 6100, 6400, 6500, 6600 and any others that become applicable, and updates to ensure access to regulations and standards for training and other quality management purposes
• Maintain a current manual using regulatory guidelines and operational protocols for each of the following positions: PSs, Life Sharing Specialists, and QIDPs, regarding their performance requirements relative to Active Treatment programming and annual plan implementation and execution; use their understanding of these requirements to review program performance and train staff accordingly
• Maintain records, including but not limited to completed audit records and survey results per policy
• Create, review, update, and maintain a current file of all QI tools used as part of the CQI, including tools for chart audit, medication audit, physical site audit, finance audit, meal observations, data audits, etc. as needed based upon new regulations, best practices, and agency policies and procedures to ensure program compliance and provision of quality services
• Respond to requests for program review, with tasks including but not limited to specific auditing of finance items/purchases matching inventory sheets, auditing of implemented diet and execution of meals, implementation of turn schedules including occasional off-hours visits as needed
• Complete Peer Reviews of investigations completed by the Risk Management department to ensure appropriate checks and balances for investigation timeliness, thoroughness, speed, and objectivity based on the ODP Certified Investigator Peer Review Manual
• Demonstrate responsibility through responsiveness to others and competent follow up on matters requiring additional attention, including but not limited to any concern brought up during an audit, review, discussion, etc. and ensuring that appropriate follow up actions are taken (such as ensuring an incident report is completed)
• Perform other duties as assigned

IMMEDIATE SUPERVISOR: Director, Quality Improvement

DIRECT REPORTS: None

CONTACTS: Elwyn personnel; individuals supported, parents, and family members; federal, state, regional, county, and local agency personnel; and visitors.

EDUCATION/EXPERIENCE/SKILLS REQUIREMENTS:

• Must be Qualified Intellectual Disabilities Professional (QIDP) qualified:
  
  
  
  • At least one year of experience working directly with persons with intellectual disabilities or other developmental disabilities AND
  • Is either a physician and surgeon, or a osteopathy physician and surgeon, a registered nurse, or a human services professional possessing at least a bachelor's degree in a human services field, including but not limited to sociology, special education, rehabilitation counseling, psychology, all professional disciplines (e.g., Occupational Therapist, Physical Therapist, physical therapy assistant, speech-language pathologist, audiologist), academic disciplines associated with the study of human behavior (e.g., speech communication, gerontology), human skill development (e.g., counseling, human development), humans and their cultural behavior (e.g. anthropology) or study of human condition such as literature, the arts
  
  
  
  
• Demonstrated ability to work effectively as part of a team and in leading a team through a quality improvement process
• Ability to work in a fast-paced environment and manage and prioritize multiple, often competing, priorities
• Demonstrated strong attention to detail
• Must have highly developed time management and organizational skills
• Must possess excellent customer interaction, collaboration, presentation, and written and verbal communication skills
• Demonstrated excellent judgment with the ability to independently solve problems and make decisions with little or no need for direct supervision
• Demonstrated ability to anticipate future needed changes or identify problem areas and take effective actions
• Must possess excellent customer interaction, collaboration, presentation, and written and verbal communication skills
• Demonstrated intermediate experience with Microsoft Office applications, including Word, Excel, Outlook, and PowerPoint
• Obtain and maintain Pennsylvania Office of Developmental Programs Quality Management Certification status
• Current or past certified ODP investigator certification preferred
• Knowledge of Electronic Health Record (EHR) / Electronic Medical Record (EMR)
• Must have current, valid driver's license in state of residence, three (3) years driving experience in the United States, and acceptable driving record