Center Executive Director/NHA
Loch Raven Center is a 113 bed nursing facility offering sub-acute and long term care. Also has a transitional care unit., POSITION SUMMARY: Create an environment where staff members are highly engaged and are focused on providing the highest level of clinical care and compassion to patients, residents and families. Responsible for assuring that the center operates in full compliance with Federal and State regulations while Doing the Right Things, which will result in high levels of performance in each of the Genesis Strategic Focus Areas. The Center Executive Director is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Center Executive Director administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents., Business Excellence 1. Assures that the QAPI Process is understood and utilized by all members of the Center Leadership Team to continually improve all aspects of Center performance as measured by the Center Performance Scorecard. 2. Oversees and assures an efficient Refer to Admit Process which maximizes Center occupancy. 3. Develops an annual business plan and budget which will serve as a roadmap to maximize the overall performance of the Center as measured by the Center Performance Scorecard. 4. Assures all aspects of the Center physical plant and environment are maintained at a high level. 5. Conducts all relevant committee meetings as required. 6. Follows company Administrative Policies (see Administrative Policy Manual). 7. Performs other duties as assigned. Staff Excellence 1. Responsible for assuring that Genesis Core Values and Promises become a reality in all dealings with Center staff members. 2. Develops and implements annual People Plans that improved the quality of work life for all staff members and creates a high level of employee engagement. 3. Works in close collaboration with the Center Nurse Executive and department heads to assure professional development and career goals are met. 4. Assures compliance and consistent application of all Personnel Policies and Practices. Clinical Excellence 1. Is highly visible throughout the Center on all shifts and days of the week to develop positive relationships with residents, patients, family members and staff to assure that the needs of all are being met. 2. Works in close collaboration with the Center Nurse Executive, Medical Director and Director of Rehab to assure high quality clinical outcomes, appropriate level of hospital readmissions, acceptable survey results and the best possible 5 Star rating. 3. Assures that staffing levels in all departments are appropriate to meet the needs of all patients and residents. 4. Confers with consultants to various departments concerning problem areas and utilizes the QAPI Process to improve performance. 5. Creates an environment that is focused on patient and staff safety. Conducts required fire and disaster drills and maintains compliance with legal, safety, health, fire and sanitation codes. Customer Excellence 1. Create a culture of Service Excellence which focuses on the patient experience, and is responsive to patients/families concerns and grievances. 2. Utilizes feedback received from the Short-Stay Patient Satisfaction Survey and Friends and Family Survey in the QAPI Process to achieve the highest possible level of customer Satisfaction. Compliance 1. As the Center Compliance Liaison and Privacy Officer designee, provides leadership and support for the Compliance and Ethics Program within management area. 2. Center Executive acts as Civil Rights Coordinator and promotes compliance with Sec.1557 of the Patient Protection and Affordable Care Act (ACA) and associated laws and regulations that prohibit discrimination. Investigates grievances alleging non-compliance with Section 1557. 3. Complies with and promotes adherence to applicable legal requirements, standards, policies and procedures including but not limited to those within the Compliance and Ethics Program, Standard/Code of Conduct, Federal False Claims Act and HIPAA. 4. Attempts to resolve any compliance issues brought to his/her attention, and reports all significant compliance issues to the Compliance Officer, and assists in their resolution in any way necessary. 5. Ensures timely and accurate reporting and responses to compliance and HIPAA-related issues and monitors the implementation of corrective action plans related to such issues. 6. Ensures that staff participates in orientation and training programs including but not limited to all required compliance courses and relevant policies and procedures, and that such training is properly documented. Participates in compliance and other required training programs. 7. Provides open lines of communication regarding compliance issues within management area and access to the Integrity Line, and ensures that retaliation against staff who report suspected incidences of non-compliance does not occur. Promptly reports concerns and suspected incidences of non-compliance to supervisor, Compliance Liaison and/or to the Compliance Officer. 8. Participates in education, monitoring and auditing activities and investigations, and implementing quality assurance and performance improvement processes, as required. 9. Completes performance reviews and determines compensation and promotions based on the accomplishment of established standards that promote adherence to compliance and quality standards. 10. Prepares compliance reports, as required.