• Implements a comprehensive safety/quality/performance improvement program inclusive of the analysis and trending of data related to initiatives• Assist in the development and implementation of organizational policies to assure compliance with state and federal regulations• Chair the QI Committee and serve as a member of all appropriate QI subcommittees and process improvement teams• Collaborate with the Director of Clinical Services and Medical Director to ensure that clinical services are provided in accordance with standards established through state and federal regulations• Monitors compliance with policy and procedures for regulatory compliance, evidence-based care, and standards of practice• Educates leadership and associates regarding regulatory issues, new statutes/guidelines, and safety/quality/QI activities• Prepare quarterly reports for the Board of Directors, CMS, UR Committee, and QI Committee• Oversee CMS and state audits, prepare and submit all audit materials, main contact person for auditors, coordinate implementation of corrective action plans• Actively participate in IDT and care plan meetings as a resource for appropriate care and compliance• Former member of the NPA Quality Committee, Education Committee and Performance Measures Committee• Perform documentation review to ensure compliance and quality care, as well as assist with EMR questions• Serve as the Medicare Compliance Officer responsible for detecting, reporting, and resolving instances of fraud, waste, and abuse• Serve as the Corporate Compliance Liaison responsible for detecting, reporting, and resolving HIPAA violations, standards of conduct violations, conflict of interest concerns, etc.• Ability to multitask and meet multiple deadlines while maintaining high-quality work

• Closely collaborate with the attending physician, patients and their families, and other patient care team members to provide and maintain continuity of patient care to achieve excellent pain and symptom management and high-quality end-of-life care for the patient.• Assess and reassess all physical, environmental, and emotional factors to determine hospice needs for patients in the home setting.• Works in cooperation with the family/caregiver and IDT to meet the emotional needs of the patient/family/caregiver.• Supervise and oversee CNAs providing care to patients

• Responsible for the overall operation of the nursing department in accordance with current federal, state, and local standards and regulations• Assisted in developing and implementing tracking reports and reviewing and reporting weekly, monthly, and quarterly department audits. Participate in the QAPI steering committee and different PIP teams.• Review of resident medical records, including diagnosis codes, RUG-IV levels, and payer source. • Review of Quality Measures and completing MDSs.• Participate in Medicare audits, including review of electronic charting for discrepancies and preparing the nursing department for CMS survey.• Collaborated on the development of the nursing department training program, the national dignity program, and many other department programs and training.