Position Summary:

The Quality Assurance Nurse provides total record review of all Medical Records to ascertain appropriate, adequate, effective, and efficient documentation of all patient care and reflects compliance with all the State and Federal regulations and the VNAHHS Policies and Procedures. Develops a comprehensive Annual QA/PI/UR Plan for the agency and the implementation of the approved plan.

Essential Duties and Responsibilities:

• Reviews on a concurrent basis the Medical Records of the patient in accordance with the accuracy of the OASIS to the development of the POC.
• Utilizes a comprehensive Chart Audit Tool to collect data on the patient’s chart; to monitor deficiencies of clinicians for trends and patterns; to educate clinicians on improving documentation and the correction of deficient notes as appropriate.
• Tabulates and summarizes finding in the Medical Record audits by organizing data and reporting data on the following criteria: Appropriateness, Accuracy, Effectiveness and Efficiency.
• Develops a plan to improve OBQI data by developing Excellence in Clinical practice pathways with interdisciplinary members. Tracks the indicators chosen per quarter and report to the QA/PI Committee Meeting.
• Reviews concurrent notes for qualitative and substantive values and to make sure that the POC are followed.
• Provides oversight for the other QA nurses and assist in their orientation and day-to-day activities.
• Collaborates with the District Managers on various documentation deficiencies/compliance issues found during the course of the QA review process.
• Conducts telephone Surveys on active patients to ascertain that their needs are being provided by the agency to their satisfaction.
• Implements the Patient Satisfaction Survey Process on all discharge patients and tabulate the results for presentation to the Quarterly QA/PI Committee Meeting.
• Assures that the Policies and Procedures are reflected and followed by clinicians during their patient care and correctly documented in the chart.
• Promotes an awareness of the highest quality of patient care to the clinicians that the agency expects for every patient we service.
• Performs other related duties of which the above are representative.

Minimum Qualifications:

• Education: Graduate from an accredited College or School of Nursing.

• Experience: Current experience in Home Health within the past 3-5 years, with QA experience and knowledge of the State and Federal Regulations.

• Licenses: Current Nurse (USRN) license to practice in the state of California. With CPR certificate is an advantage.

Knowledge and Skills:

1. Clear understanding of the QA, PI and UR process and the OBQI and the Home Health Compare data.

2. Knowledge of the agency policy and procedures, the COPs and the State regulations in Title 22 and other Federal and accreditation standards and mandates.

3. Excellent oral and written communication skills.

4. Ability to manage multiple projects and priorities,

5. Responsible for maintaining professional skills and continuing education.

6. Computer skills.

7. Highest professional standards and ethics.

• Equipment Used: Computer, pager, telephone, fax, copier and other tools of trade.