Director of Quality Assurance and Quality Improvement (QA/QI)

Quality Assurance & Improvement:

• Develop, implement, and manage a comprehensive Quality Assurance and Quality Improvement (QA/QI) program.

• Conduct regular internal audits of clinical, administrative, and operational functions.

• Collect, analyze, and report data on performance metrics; identify trends and areas for improvement.

• Coordinate agency-wide quality improvement initiatives and ensure corrective action plans are implemented and followed up.

• Prepare and present QA/QI reports to senior leadership and regulatory bodies.

Policy & Procedure Oversight:

• Oversee the creation, revision, implementation, and agency-wide distribution of all policies and procedures.

• Ensure all policies are current, compliant with applicable federal, state, and local regulations, and aligned with agency practices.

• Collaborate with department heads to standardize operational procedures across programs.

• Conduct regular policy reviews and maintain documentation of policy updates and staff acknowledgments.

PREA Compliance:

• Serve as the agency's PREA Compliance Manager and ensure full adherence to all PREA standards.

• Maintain all PREA-related documentation and ensure timely investigation and reporting of incidents.

• Train staff and educate clients on PREA rights and procedures.

• Coordinate and support PREA audits and self-assessments.

ACA Compliance:

• Ensure the facility meets and maintains ACA accreditation standards.

• Lead the preparation, documentation, and ongoing readiness for ACA audits and reviews.

• Align policies and practices with ACA benchmarks and facilitate related staff training.

DOC Compliance:

• Oversee compliance with New Jersey DOC standards and contractual requirements.

• Serve as the primary liaison for DOC inspections, audits, and communications.

• Ensure timely submission of reports and incident notifications as required by DOC.

Leadership & Collaboration:

• Provide compliance guidance and technical assistance to department heads and program leaders.

• Chair or coordinate the agency's QA/QI committee and other compliance-related teams.

• Deliver training on quality, compliance, risk management, and agency policy.

• Work closely with Human Resources, Clinical, Admissions, and Operations to ensure agency-wide alignment with standards and policies.