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Director of Quality Improvement and Compliance for IDD Programs

Media, Pennsylvania
Closing date
Jul 31, 2021

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Position Type
Dean / Department Head
Organization Type
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POSITION SUMMARY: Ensure the delivery of quality services to individuals in IDD residential programs, day programs, and Elwyn Industries in compliance with external and internal regulatory criteria and/or standards through the development, implementation, oversight, analysis and potential realignment of a comprehensive and continuous quality improvement program as required by regulations. Direct all quality improvement personnel in IDD Services and in the Records Department. Develop and provide training in quality improvement procedures and outcome-based measures for all IDD employees. Design, develop and facilitate quality improvement, utilization and safety for individuals supported in connection with risk management activities, incident management, policies and procedures. Oversee compliance with the physical site and fire safety of all service locations. Participate in on-call responsibilities.


* Coordinate, integrate and implement comprehensive and continuous quality management program, including design, plan, data collection, analysis, and reporting on program quality objectives for the following departments: Community Residential Programs (CRS), campus and community Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Adult Day Programs and Elwyn Industries, and Safety and Security (as related to IDD services)
* Coordinate, integrate, implement and oversee comprehensive and continuous quality improvement systems and activities including data collection and analysis of family satisfaction and consumer satisfaction, including complaints/suggestions/concerns and incident reporting; key performance indicators, Utilization Reviews, Human Rights Team (HRT)
* Implement the Office of Developmental Programs' (ODP) mandated Provider Qualifications process and the ODP Quality Assessment and Improvement (QA and I) process
* Coordinate Independent Monitoring for Quality and National Core Indicators with ODP and Pennhurst monitors
* Perform internal investigations as a certified investigator as needed
* Submit quarterly updates on all quality improvement activities to the Executive Director, ICFs/IID & Quality Initiatives
* Provide supervision of assigned staff in the areas including, but not limited to, recruitment, selection, leadership, coaching, training, performance management, promotion, discipline and termination
* Direct the work of the Quality Improvement and Records Departments to ensure collaboration between quality management and quality improvement
* Develop policies and procedures related to quality improvement and program objectives
* Design, coordinate, and provide in-service training to support compliance, program development and thorough understanding of all applicable regulations for employees in all of IDD Programs
* Develop and deliver training for all directors, Qualified Intellectual Disabilities Professionals (QIDPs) and program specialists to ensure consistency in the delivery of program services
* Monitor program compliance with quality improvement standards, including but not limited to, the Department of Health and the Federal Intermediate Care Facilities/Individuals with Intellectual Disabilities (ICF/IID) standards, applicable waiver regulations (Chapter 6100), Licensing Regulations (2380, 2390, 3800, 6400 and 6500) and other applicable regulations, as implemented
* Facilitate the survey process for external audits including but not limited to gathering data/documentation, scheduling space, ensuring surveyors needs are met, greeting surveyors, being point person for surveyors' questions and requests, getting answers as needed, scheduling interviews if they so request, and scheduling the exit interviews
* Develop corrective action plans/plans of correction (POCs) in conjunction with operations staff ensuring submission of an approved POC
* Organize and direct quality improvement specialists in the task of monitoring readiness and preparedness for inspection of all IDD Services
* Communicate on an on-going basis to residential and day/work program directors regarding findings and other issues important to the operations of their respective programs
* Develop and maintain a thorough understanding of the service area's core competencies, current strengths and challenges, assist the directors in developing programmatic enhancements, changes, and strategies to meet the needs of a changing population of individuals served, and to distinguish service area core competence in the future
* Develop and implement systems for periodic internal evaluations of compliance with standards and systems for feedback and plans of correction
* Develop and maintain quality performance and measurement indicators, evaluate the usefulness of these indicators and recommend corrective action plans for noted operating problems
* Fulfill the role of HCSIS Administrator by adding new users to the system, changing user roles, disabling users when requested, and running admin review reports
* Perform functions relative to the PROMISe system including but not limited to enrolling new service locations to PROMISe via electronic enrollment application in the PA Department of Human Services Medical Assistance program; updating ownership and control interest disclosures as applicable, and completing revalidation of locations as required
* Obtain and maintain ODP's Quality Management Certification utilizing it to ensure program compliance with regulations, safeguard the health and safety of individuals receiving services, implement positive practices, and offer the highest quality services that promote choice and control in individuals' everyday lives
* Ensure Elwyn IDD Incident Management protocols are developed, implemented and followed in accordance with program regulations
* Represent Elwyn as the incident management representative as per the Pennsylvania Department of Human Services, Office of Developmental Programs Bulletin #00-21-02, Incident Management, issued March 1, 2021
* Participate in the QI/Incident Management on-call rotation
* Perform other duties as assigned

IMMEDIATE SUPERVISOR: Executive Director, ICFs/IID & Quality Initiatives

DIRECT REPORTS: QI Specialists, QI Associate Director, Investigation Specialists

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


* Must be Qualified Intellectual Disabilities Professional (QIDP) qualified:

(a) At least one year of experience working directly with persons with intellectual disabilities or other developmental disabilities AND

(b) 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

* Master's Degree in a human services related field preferred
* Five (5) years' experience in residential service for people with disabilities management including but not limited to quality improvement, program administration and/or direct program operations supervision; experience working with people with intellectual and/or developmental disabilities preferred
* Knowledge in applicable regulations including but not limited to Pennsylvania regulations 2380, 2390, 3800, 6100, 6400, 6500, 6600, Home and Community waiver regulations and Pennsylvania State Operations Manual Appendix J for Intermediate Care Facilities
* Five (5) years' supervisory experience including but not limited to performance management
* Obtain and maintain Pennsylvania Certified Investigator status
* Obtain and maintain ODP's Quality Management Certification
* Demonstrated ability to work effectively as part of a team including leadership ability
* Must be organized with excellent attention to detail
* Must possess excellent customer interaction, collaboration, presentation, written and verbal communication skills
* Demonstrated intermediate experience with Microsoft Office applications, including Word, Excel, Outlook, and PowerPoint; Publisher and report-writer experience preferred
* Must have a current, valid driver's license in state of residence, three (3) years driving experience, and an acceptable driving record

PHYSICAL DEMANDS/ENVIRONMENTAL PROFILE: See Physical Demands Checklist below which represents the general physical demands and environment conditions to which the employee holding this position must meet, in addition to the duties and responsibilities listed above, to successfully perform the essential functions of this job. Elwyn will engage otherwise qualified candidates for this position whose disabilities may require reasonable accommodations to enable an individual to perform the essential functions.

Elwyn reserves the right to revise or change job duties and responsibilities as needed. This job description is not meant to be an all-inclusive statement of duties and responsibilities of the job nor does it constitute a written or implied contract.

Elwyn is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation and identity, gender identity, national origin, citizenship status, genetic information, disability status, military or veteran status, marital or family status, political activities or affiliations, or any other characteristic protected by local, state, and federal law.


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