Overview

The Regulatory Compliance Advisor is responsible for overseeing Regulatory

compliance and the Quality Review process that supports compliance to state and federal

regulations, as well as GHC policies and procedures. He/she will oversee the process to

ensure quality reviews will be conducted at each center a minimum of annually. This

role will collaborate with Market Advisors, Market Clinical Advisors, Center Leadership,

food and nutrition services, rehab services, property management, and others as needed,

to ensure their involvement in the process.

Responsibilities

• Collaborate with Market teams to create an overall survey improvement plan as well as
  
  

individual center survey improvement plans to include focus on past survey history,

Quality Review results, leadership training needs and a roadmap for completion of CEP’s

• Establish priority centers based on Health Inspection ratings, SFF status, Government
  
  

oversight, Special licenses, or other special circumstances.

• Participate in Quality Reviews in the Market. Ensure the Quality Review is scheduled no
  
  

less than 90 days prior to the survey window opening.

• Provide support during all Health inspections on site or remotely during the survey,
  
  

ensure plan of correction is submitted timely and validate readiness for revisit.

• Collaborate with Market Advisor, Clinical Advisor or other designated Market team
  
  

members to ensure coordination and appropriate selection of team members, sample

selection, and informing the Center of the date and items needed for the Quality Review.

• Will ensure the approved Quality Review process will be followed accordingly and
  
  

Critical Element Pathways are utilized. Support Market team in assessing center staff’s

ability to identify issues.

• Oversee that coaching is part of Quality Review process for Center staff in survey
  
  

management to help them build confidence and be well prepared for the survey.

• Ensures process in place for an informal exit review with the Center staff so center may
  
  

begin immediate correction of identified issues.

• Ensure process is in place for Quality Review findings report is provided to the
  
  

Administrator within 10 days of the Quality Review Collaborate with others to identify

resources/processes needed to assure action plan has been completed prior to survey

• Schedule validation visit.
• Provide feedback to the National team to ensure the Quality Review process remains current with changing regulations.
• Analyze effectiveness of Quality Review process by comparing Quality Review and
  
  

actual survey findings.

• Maintain knowledge of state and federal long-term care regulations.
• Be a resource for federal and state regulatory changes and inform Market team and
  
  

Center leaders of regulatory changes.

• Ensure processes in place to evaluate Center staff ability to manage the survey process
  
  

and interact with surveyors.

• Prepare and present training sessions for Market related to survey process, regulatory
  
  

guidelines and any other related issue identified in coordination with the Market/National

team.

• Provide feedback regarding findings and need for changes to policies, programs, or
  
  

training.

• Ensure survey information has been entered into the regulatory tracking system.
• Works with Market and National team as appropriate to:
• Respond to critical events
• Support clinical and operations practice
• Leadership and direction on key clinical projects;
• Establish relationships with regional CMS staff and state survey agencies
• Identify SFF Centers, SFF candidate centers, Low Health Inspection Star ratings and
  
  

implement Focus Center calls

• Collaborates with the Market Team to understand and improve the quality outcomes for
  
  

residents, families and staff at designated centers.

• Serve as resource expert on available resources including but not limited to Team TSI,
  
  

Compliance Store, AAPCN, Care Data Hub., QSEP

• Meet with New NHA/DON’s to review survey history and educate on Genesis tools and
  
  

resources related to Regulatory compliance.

• Other duties as assigned.
  
  

Qualifications

• R.N. or Bachelors in healthcare field preferred. Three to five years of experience
  
  

in the long-term care industry with preferred experience in regulatory compliance.

• Must have an understanding of long-term care guidelines and regulations and be
  
  

knowledgeable in the state survey process.

• Must be proficient in observation of both resident care and the Center
  
  

Environment, And Reviewing Charts And Other Regulatory Documentation Requirements.

• Must be experienced in interpreting the regulation and associated F-tags and
  
  

applying them to the findings.

• Must be knowledgeable of the CMS enforcement process related to surveys, i.e.,
  
  

CMPs, DPNAs, etc.

• Must be able to travel extensively.
  
  

#GHC25

Posted Salary Range

USD $150,000.00 - USD $160,000.00 /Yr.