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Responsible for ensuring multidisciplinary quality assurance and performance improvement (QAPI) activities within the facility that are in accordance with established requirements.   

Establish and implement effective, comprehensive, data driven QAPI programs that focus on systems of care including indicators of outcomes of care, quality of life and resident and staff satisfaction.     

Develop the five elements of a QAPI program and coordinate the required activities.     

Evaluate programs and implement changes as necessary to improve programs and assure compliance with regulatory requirements.     

Communicate revised plans and changes to facility management and governing body.     

Develop and implement appropriate plans of action to correct identified deficiencies.     

Complete necessary forms, reports, etc., and submit to the Administrator as required.     

Schedule QAPI Committee meetings at least quarterly and notify members.   

Maintain a reference library of written QAPI material, laws, etc., necessary for complying with current standards and regulations.      

Provide reports/recommendations to the Administrator as necessary/required concerning the operation of the QAPI program.     

Assume the authority, responsibility and accountability of directing the QAPI department.     

Review the facility’s quality measures and survey reports to assist in identifying potential problem areas. Make reports to committee as necessary.     

Proactively identify areas of concern for noncompliance and develop a plan of action, measurement, training and follow-up; develop reports to document these initiatives.      

Participate in facility surveys as necessary or as directed.     

Serve as chairperson of the QAPI Committee.     

Meet with the QAPI Committee monthly to review all assessment tools designed, all data collection reports and all activities carried out by departments, services or committees that have a direct impact on resident care and safety.     

Serve on various committees of the facility (i.e., pharmacy, safety, resident care, policy advisory, etc.) as deemed appropriate and as appointed by the Administrator.