Quality Coordinator RN

Position Summary:
The QAPI Coordinator is responsible for developing, implementing, and monitoring the hospice's Quality Assurance and Performance Improvement (QAPI) program. This role ensures compliance with federal, state, and accreditation standards, including the integration and utilization of the HOPE (Hospice Outcomes and Patient Evaluation) tool to enhance patient care and outcomes. The QAPI Coordinator also plays a critical role in ensuring survey readiness and managing the survey process for regulatory and accreditation compliance.

Additionally, this position oversees IDG (Interdisciplinary Group) hospice compliance, ensuring collaboration and adherence to regulatory standards within the IDG team.

Education and Experience:

• Graduate of an approved School of Nursing
• Current RN License in State of Ohio
• Minimum of two years of experience in Medical / Surgical, Oncology or community health nursing.
• Hospice experience preferred.

Special Skills and Requirements:

• Valid driver’s license and current auto insurance
• Detail oriented with excellent communication, documentation, and organizational skills
• Ability to follow instructions, and work independently without supervision.
• Travel to other sites as needed. Travel may be in inclement weather.
• Ability to lift 25 lbs of supplies or equipment
• Requires various amounts of sitting, standing, twisting, turning, bending, lifting and walking.

Key Responsibilities:

• Quality Improvement:
• Oversee the implementation and monitoring of the QAPI program.
• Assist with the development and implementation of organizational policies and procedures.
• Develop, implement, and maintain an Agency-wide QAPI program and related activities.
• Assist with the completion of all quality reviews and root cause analysis for the agency.
• Help prepare Quality Improvement reports using comparative data charts including benchmarking.
• Analyze Hospice Item Set (HIS) and HOPE tool data for trends and opportunities for improvement.
• Review and analyze Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys for trends and opportunities for improvement, create scorecards, and report results.
• Monitor utilization and service quality through quality measures, satisfaction surveys, and complaints, and report on results.
• HOPE Tool Integration:
• Train staff on the use of the HOPE tool for patient assessments.
• Ensure accurate and timely completion of HOPE assessments, visits, documentation and billing at required time points.
• Manage and track when symptom follow-up visits (SFV) are needed as required by CMS.
• Accurately update admission visit and hospice update visit (HUV) records when SFVs are required and properly document sections completed on the visit note.
• Track, compile, and submit required HIS and HOPE tool data to Medicare within time requirements; ensure data is accepted by CMS/IQUIS in a timely manner.
• Audit symptom impact questions for completeness and accuracy, ensuring documentation supports symptom impact screening codes in clinical notes.
• Assist with education on the HOPE tool implementation and ongoing compliance.
• Survey Readiness and Management:
• Maintain ongoing preparedness for regulatory, licensure, and accreditation surveys.
• Coordinate survey activities, including documentation review, staff preparation, and facility readiness.
• Serve as the primary liaison during survey time and address any findings or follow-up actions.
• Assist department managers and employees in preparing for federal, state, and accrediting body surveys.
• IDG Compliance and Oversight:
• Monitor and ensure compliance of IDG activities with Medicare Conditions of Participation (CoPs) and other regulatory requirements.
• Provide guidance and support to the IDG team to promote consistent adherence to quality standards.
• Facilitate IDG meetings, ensuring accurate documentation and effective interdisciplinary collaboration.
• Compliance and Reporting:
• Maintain documentary evidence of the QAPI program and be able to demonstrate its operation to federal, state, and accrediting body surveyors.
• Prepare and submit required reports to regulatory agencies and leadership.
• Participate in accreditation activities and survey preparedness.
• Coordinate efforts to…