Director Of Clinical Compliance & Education

POSITION SUMMARY: Maintains The Director of Clinical Compliance and Education is responsible for regulatory compliance for all issues involving licensure and certification of all Hospice locations. The position ensures that all the practices of the company's hospice division meet federal, state and local laws, company policy and procedure standards of professional practice. Additionally, the position ensures quality and safe delivery of hospice services by developing, implementing and evaluating both proactive and reactive Quality Performance Improvement, Education Programs, and activities.

ESSENTIAL DUTIES:

• Complies with accepted ethical conduct and professional standards of nursing practice as set forth by the American Nursing Association (ANA)
• Complies with accepted ethical conduct and professional standards of health care compliance in accordance with HCCA standards
• Serves the Company with the highest sense of integrity, exercises unprejudiced and unbiased judgment on their behalf Upholds and supports Company efforts to institute and maintain an effective compliance communication program for the organization, including promoting a) use of the compliance hotline, b) heightened awareness of standards of conduct, and c) understanding of new and existing compliance issues and related policies and procedures
• Identifies potential areas of compliance vulnerability and risk within the hospice program, develops and implements corrective action plans for resolution of problematic issues, and provides general guidance on how to avoid or deal with similar situations in the future
• Provides reports on a regular basis and, as directed or requested, to keep the Corporate Compliance Committee and senior management informed of the operation and progress of hospice division compliance efforts
• Manage a team of hospice quality personnel of 10 or more employees
• Investigates hospice division compliance issues and privacy issues under the direction of the CCO and collaborates with other departments (for example, human resources, chief financial officer, and Director of Information) to direct hospice compliance issues to appropriate existing channels for investigation and resolution
• Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate or required under the direction of the CCO
• Collaborates with outside legal counsel on hospice nursing practice issues, clinical-legal issues and regularity compliance issues as directed by the CCO
• Reviews new regulations and updates and distributes information as appropriate to offices, divisional personnel, etc.
• Participates in acquisition activities including due diligence and integration implementation as directed by CCO
• Participates in the review, analysis, and appraisal of the effectiveness of various clinical and quality programs and procedures, including but not limited to the review and analysis of the hospice quality reporting program (HQRP)
• Ensures all hospice agencies appropriately participate in the Medicare HQRP. Ensures all CAHPS and HIS data is submitted in a timely manner
• Ensures contracts with all CAHPS/HQRP vendors remain active and meet all CMS requirements
• Acts as Secretary for the Hospice Governing Body. Gathers and reports data for annual Governing Body Meetings and ad hoc meetings as required
• Provides oversight of hospice compliance with regulatory requirements including but not limited to the development and maintenance of internal audit processes and programs
• Provides oversight of hospice response to regulatory updates and requests including but not limited to the development and maintenance of internal audit processes, and external audits (ADRs, CERTs, UPIC, etc.). Provides a reporting of outcomes as requested to the Governing Body
• Ensures that all external audit requests are responded to in a timely manner. Provides oversight and guidance of appeals submission as needed including participating in Informal Dispute Resolution (IDR) and state and Federal appeals hearings

JOB DESCRIPTION
Date Revised: 11/2019 Addus HomeCare | Hospice Quality Director 2

• Coordinates oversight activities including agency survey readiness, ACHC accreditation prep, development and submission of post-survey corrective action plans, and intervention in troubled offices in collaboration with hospice operations leadership
• Ensures the quality assurance performance improvement activities of the company's hospice division are carried out. Develops/revises the Corporate QAPI Plan based on high risk, problem-prone areas identified as a result of audits and local agency QAPI efforts
• Identifies the need for overall hospice regulatory and education activities for the hospice division based on an annual needs assessment in collaboration with the Manager of Clinical Education and hospice division leadership
• Provides oversight of the planning, development, approval, and implementation of continuing education (CE) activities and ensures compliance with all state and accrediting body requirements. Ensures all approved Continuing Education (CE) credits are issued promptly and reported to state licensing agencies as required
• Maintains a high degree of confidentiality at all times due to access to sensitive information
• Maintains regular, predictable, consistent attendance and is flexible to meet the needs of the department
• Follows all Medicare, Medicaid, and HIPAA regulations and requirements
• Abides by all regulations, policies, procedures and standards
• Performs other duties as assigned

PERFORMANCE RESPONSIBILITIES:

• Maintains positive internal and external customer service relationships
• Maintains open lines of communication
• Plans and organizes work effectively and ensures its completion
• Meets all productivity requirements
• Demonstrates team behavior and promotes a team-oriented environment
• Actively participates in continuous quality improvement
• Represents the organization professionally at all times

POSITION REQUIREMENTS & COMPETENCIES:

• A Registered Nurse with a Baccalaureate or higher degree and a minimum of five (5) years of experience in home health/hospice. Previous hospice quality improvement, compliance, and/or operational management experience at a senior corporate level. Strong knowledge of hospice Conditions of Participation, billing and claims requirements, and State/Federal regulations required
• Experience in developing, implementing and evaluating policies and procedures, as well as, quality assurance and education programs and activities in home care/hospice settings required. Strong presentation skills preferred
• Experience investigating and documenting hospice/home health related compliance issues. Compliance certification (CCP, CHC, etc.) a plus
• Experience in accreditation activities, survey preparation, plans of correction in home care /hospice settings - ACHC, CHAP, and/or Joint Commission knowledge preferred
• Experience in responding to regulatory requests such as: ADRs, CERT audits, TPEs, UPICs, etc. required. Knowledge of Medicare and Medicaid appeals processes preferred
• Previous experience working with home care/hospice regulatory, licensing, and certification issues in a multi-office, multi-state environment required
• Previous experience supervising others in a remote capacity
• Demonstrates an ability to function in an autonomous role with minimal supervision
• Excellent organizational, interpersonal, telephone, written and communication skills
• Must possess the disposition and personality to work harmoniously with a wide variety of people and all levels of staff, and interact professionally as a member of a multi-disciplinary team
• Ability to work flexible hours as required meeting identified company needs
• Occasional travel required
• Ability to adapt to changing organization needs
• Speaks, writes, reads and comprehends English
• Excellent oral and written communication skills
• Ability to multi-task under tight deadlines
• Strong communication skills and interpersonal skills

JOB DESCRIPTION
Date Revised: 11/2019 Addus HomeCare | Hospice Quality Director 3
WORKING CONDITIONS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit, talk, hear; use hands to finger, and handle controls. The employee frequently is required to reach with hands and arms. The employee is occasionally required to stand, walk, and stoop. Specific vision abilities required by this job include close vision and the ability to adjust focus.
ENVIRONMENT: Moderate noise level similar to a typical office environment with computers, printers, and work activity.
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This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.