Mgr-Regulatory Compliance (Full Time)
POSITION SUMMARY: The Manager, Regulatory Compliance is responsible for managing a Pre-Survey process that supports compliance to state and federal regulations, as well as GHC policies and procedures. He/she will manage the process so that Pre-Surveys are conducted at each center a minimum of annually. The Manager, Regulatory Compliance will collaborate with food and nutrition services, rehab services, property management, and others as needed, to ensure their involvement in the process.
RESPONSIBILITIES/ACCOUNTABILITIES: 1. Prepare a pre-survey schedule for area so that Center Pre-Surveys occur no less than 30 days prior to survey window opening. Communicate the Pre-Survey schedule to all appropriate Area personnel. 2. Coordinate all activities of the Pre-Survey including selection of team members, sample selection, and informing Center of the date and items needed for the Pre-Survey. 3. Conduct the Pre-Survey process in the Center using the Corporate Pre-Survey process and audit tools. Assess Pre-Survey team members’ ability to identify issues. 4. Evaluate Center staff ability to manage the survey process and interact with surveyors. 5. Coach Center staff in survey management to help them build confidence and be well prepared for the survey. 6. Conduct an informal exit review with the Center staff so they may begin immediate correction of identified issues. 7. Send a survey findings report to the Administrator within 10 days of the Pre-Survey. 8. Review the Pre-Survey Action Plan submitted by Center. 8.1 Ensure action plan addresses each recommendation made by Pre-Survey team. 8.2 Confirm Center is meeting target dates. Document observations and recommendations. 9. Identify resources/processes needed to assure action plan is completed prior to survey. 10. Maintain knowledge of state and federal long-term care regulations. 11. Teach pre-survey team how to interpret regulations and apply associated F-tags. 12. Serve as the Area point person for federal and state regulatory changes and inform Area Clinical Operations staff of regulatory changes. 13. Collaborate with Corporate Clinical Operations and peers in other areas to ensure the Pre-Survey process remains current with changing regulations. 14. Analyze effectiveness of Pre-Survey process by comparing Pre-Survey and actual survey findings. 15. Provide routine reports to Area and Corporate management regarding findings and need for changes to policies, programs, or training. 16. Collaborate with Area Clinical Leadership regarding the need to focus on recurring survey citations. 17. Collaborate with Area Quality Leaders to ensure survey information is entered into the regulatory tracking system. 18. Monitor centers for remedies imposed and ensure that Corporate Director of Clinical Resource Management is aware of pending remedies and the risk for potential remedies. 19. Establish relationships with regional CMS staff. 20. Assist with regulatory crises management, as needed 21. Provide education to new nurses on the survey process. 22. Other duties as assigned.
Job posted: 2020-06-16