SPECIFIC RESPONSIBILITIES:

1. Assist program staff to meet Federal, State and local code and regulations and accrediting body standards.

2. Collaborate with department directors and vice presidents to ensure preparation, coordination and follow up on external audit processes.

3. Facilitate activities in support of long range strategic plans.

4. Conduct or oversee Case Record Review activities and prepare quarterly and annual Case Record Review reports, aggregating data, analyzing trends, and working collaboratively with program staff regarding follow-up activities and improvements, as required.

5. Revise and maintain 29i Policy and Procedure Manual at least on an annual basis or when a major policy shift occurs.

6. Serve as Mental Health Coordinating Unit (MHCU) Liaison, promoting compliant data entry and oversight, as well as coordination of necessary ACS and SCO Documentation upon a foster youth’s hospitalization.

7. Participate in all Quarterly Incident Review Committee meetings, and program IRCs as requested by the Director of Mental Health or PQI Director.

8. Participate in Monthly Agency–Wide and Departmental Quality Improvement meetings.

9. Facilitate the submission of Outcome Measurement reports: Track key Outcomes and Performance measurements throughout the year, aggregating data, analyzing quarterly and annual trends and working collaboratively with program staff regarding follow-up activities and improvements.

10. Utilize agency systems for on-going program data collection and trend analysis, implementing procedures to use such systems in areas such as: demographics, incidents and accidents, the conduct of investigations, program specific demographics, etc.

11. Assist with the formulation, implementation and monitoring of corrective actions to ensure program improvement including but not limited to: policy/procedure development and review, systems development and review, establishing benchmarks, personnel assignments, training, etc., tracking the implementation of corrective actions providing follow-up, as needed, with program staff.

12. Participate in Quarterly Quality Team meetings. Communicate results and recommendations to Directors of Mental Health and Quality Improvement, Vice President, etc. including the presentation of Quality Improvement reports to staff with analysis of trends. Assure recording of minutes, as appropriate.

13. In-service training of new caseworkers regarding interface with the Mental Health Department and MHCU reporting requirements.

14. Initiates and maintains communication with other SCO Departments and/or external regulatory agencies, as directed and/or appropriate, to obtain clarification on issues which have an impact on PQI issues for the program/Department.

15. Other PQI tasks as assigned.