Performance and Quality Improvement Specialist

SPECIFIC RESPONSIBILITIES

• Assist ICF programs in meeting and maintaining compliance with all applicable local, state, and federal regulations.
• Complete program audits to review systems and processes to ensure compliance with OPWDD, CMS, DOH, and agency standards.
• Conduct internal audits and inspections annually and as needed to identify areas of non-compliance.
• Prepare detailed written reports of findings and recommend corrective actions.
• Respond to OPWDD and Department of Health (DOH) audits, including preparing documentation, coordinating responses, and implementing corrective action plans.
• Support program staff in implementing and sustaining compliance with Council on Accreditation (COA) standards.
• Incident Management & Investigations.
• Ensure timely and thorough documentation of all incidents, including illness, injuries (including unknown origin), and behavioral events.
• Review and complete SCO In-House Occurrence Reports within five (5) business days of submission.
• Conduct independent investigations of reportable incidents in accordance with OPWDD Part 624, Justice Center, and agency guidelines within five (5) business.
• Prepare detailed, timely written reports using OPWDD and Justice Center-approved formats.
• Maintain certification as an investigator through the Justice Center and OPWDD-approved Incident Investigation Certification Program.
• Participate in Incident Review Committee meetings and assist with incident monitoring and trend analysis.
• Travel to multiple sites as necessary to conduct program visits and onsite investigations.
• Complete entries into the OPWDD Incident Report and Management Application (IRMA) as needed.
• Assist with the maintenance and accuracy of the agency’s incident database.
• Review, complete, and document RIA - restrictive intervention application OPWDD forms in accordance with regulatory requirements and agency protocols.
• Track and review Behavior Management Training and the use of Restrictive Behavior Management Interventions.
• Support the review of level of supervisions (LOS) for individuals with behavioral challenges.
• Participate in the Clinical Behavior Review (CBR) process.
• Collaborate with clinical teams to ensure appropriate behavioral supports are in place.
• Assist with case record reviews and the administration of consumer satisfaction surveys.
• Prepare and submit detailed quarterly and annual reports summarizing trends, findings, and recommendations.
• Participate in agency-wide Quality Council meetings and contribute to continuous improvement initiatives.
• Identify training needs related to incident management, documentation, and regulatory compliance.
• Support the development and delivery of training to program staff as needed.
• Other Duties
• Any additional tasks to support PQI and/or the program.
• Perform all other duties as assigned by the supervisor or agency leadership.

  QUALIFICATIONS

• Bachelor’s degree in Human Services, Psychology, Social Work, or related field (Master’s preferred).
• Minimum of 3–5 years of experience in developmental disabilities services, with at least 2 years in incident management or quality assurance.
• Certified Investigator through the Justice Center and OPWDD (or ability to obtain certification upon hire).
• Strong knowledge of OPWDD regulations, including Part 624, DOH standards, CMS 483 regulations and COA requirements.
• Working knowledge of ICF CMS regulations and compliance expectations.
• Excellent written and verbal communication skills.
• Strong analytical, organizational, and problem-solving abilities.
• Proficiency in Microsoft Office and incident management systems (e.g., IRMA).

 RELATIONSHIP WITH OTHERS

In addition, employees need to possess the following characteristics:

• Be a team player and able to interact in a positive manner with Administrative, Managerial, Supervisory, and line staff as well as persons receiving services and their family members
• I am sensitive to cultural differences among staff and clients within our organization, the people we serve, and their families.
• Ability to set limits, maintain role, and work collaboratively and respectfully to intervene appropriately as a quality improvement staff person.

  WORKING CONDITIONS

Local Office and all OPWDD Program environments.