Quality Improvement Coordinator

Quality Improvement Coordinator-WV Caminos West Program
Reports to: QI Manager
FLSA Classification: Non-Exempt
Last date reviewed: 9/9/2025

Position Summary:

The Quality Improvement Coordinator is responsible for organizing quality improvement (QI) activities intended to monitor and provide feedback related to the quality-of-service delivery for the Caminos West Virginia Program. This position serves as the Prevention of Sexual Abuse (PSA) Compliance Manager and is responsible for providing child facing services onsite, managing implementation and ongoing compliance with the Federal Office of Refugee Resettlement (ORR) Policy Guide Section 4: Prevention, Detecting and Responding to Sexual Abuse and Sexual Harassment and the Interim Final Rule (IFR) Part 411 on Standards to Prevent, Detect, and Respond to Sexual Abuse and Sexual Harassment involving Unaccompanied Children and ORR policies and procedures related to sexual abuse and harassment. Responsibilities include conducting facility walkthroughs, camera and real time activity audit and observations as well as working within various databases, pulling and designing reports and visuals, as well as conducting stakeholder surveys, chart audits, and discovery processes. The QI Coordinator provides support to ensure that identified essential program functions occur in accordance with state and federal regulations and meet Everstand and accreditation best practice standards.

Essential Functions:

• Model and act in accordance with Everstand’s core values: safety, empathy, relationships, and impact.
• Honor differences, acknowledge uniqueness, and amplify all voices. Participate in trainings and group experiences that explore Equity, Diversity, and Inclusion (EDI) topics. Model the use of inclusive language.
• Demonstrate and practice Everstand’s leadership mindset, “Choose kindness. Solve problems and learn together. Make it happen.”
• Attain Collaborative Problem Solving® Tier 1 certification and serve as a mentor of this practice for others.
• Assure compliance of all standards that apply to the Caminos West Program, including national accreditation, Federal and state licensure, and serve as an internal resource on all applicable regulations.
• Assist in Federal and State licensure and national accreditation activities.
• Assist staff in implementing, monitoring, evaluating and planning procedures and activities in all service delivery areas and for risk management.
• Assist in developing policies and procedures to support service delivery and funding accountability.
• Identify changes or the creation of new policy and procedures based on both program needs as well as from Federal and State regulation announcement changes. Responsible for updating all documentation in both policy and procedure manuals as well as supporting training materials. Draft new training materials as needed following significant revisions.
• Provide training on workflow and policy changes.
• In partnership with other members of the QI team, monitor the centralized QI email inbox as well as assigned digital and physical formal concern inboxes. Open new cases in the appropriate database and follow up on assigned cases as needed. Reply to questions from staff modeling best practices in customer service.

PSA Compliance Manager and Formal Concerns:

• Ensure the safety of clients by following Everstand policies, ORR policies, and the standards identified within the Interim Final Rule, and state licensing guidelines.
• Maintains a keen understanding of ORR and Everstand’s Zero Tolerance Policy and the ORR Code of Conduct, providing consultation and guidance to program leadership and talent to ensure continued understanding and compliance.
• Maintains an understanding of the legal statutes that have created the framework of the IFR/PSA including but not limited to Prison Rape Elimination Act, Violence Against Women Act, and Flores v. Reno Settlement Agreement, being able to share the legal background with program leadership and talent to ensure understanding and compliance across program operations.
• Conduct at least monthly facility walkthroughs to confirm posting of required PSA fliers, pamphlets, and brochures in all living spaces and school settings. Document compliance with standards and deliver corrective actions to the program as needed.
• Ensure ORR Direct Line telephones maintain proper functioning and are accessible to minors in care. Conduct at least monthly monitoring checks to ensure that required phone numbers are properly programmed, including the UC Sexual Abuse Hotline, Child Protective Services, local community service provider or national rape crisis hotline and other numbers such as consulates or the legal service provider. Add additional phone numbers and accessibility options as identified by program leadership and/or ORR stakeholders.
• Acts as the primary point of contact for PSA Audit processes. Provides on site support in preparation of and during internal and external PSA audits.
• Ensures that internal and external PSA Audit findings and/or related corrective action plans are addressed to achieve compliance.
• Monitors IFR compliance related to applicant screening, training and tracking of employees, contractors and volunteers for their assigned program.
• Participate in monthly PSA Compliance Manager trainings and disseminate updated policy guidelines to program leadership.
• Provide guidance to staff on correct policies and procedures when submitting serious incident reports related to sexual abuse, sexual harassment, inappropriate sexual behavior, or code of conduct violation reports.
• Pursue and maintain agreements with external resources including local rape crisis centers, law enforcement, and licensing bodies to coordinate procedures if sexual abuse or harassment is reported.
• Update agency policy and procedures related to Prevention of Sexual Abuse.
• Facilitate PSA and ORR Code of Conduct training to staff. Provide consultation to Training with the Training Department to ensure training materials are updated and relevant.
• Conduct unannounced video camera monitoring and audits at least monthly across all areas of Caminos programming, documenting potential areas of non-compliance and identifying areas where additional staff training may be needed. Communicate findings and recommendations to program leadership.
• Ensure unannounced rounds are being completed and documented in accordance with State and Federal requirements.
• Serve as the point of contact for ORR's PSA Coordinator and Everstand’s PSA Compliance Administrator regarding matters relating to ORR Policy Section 4 and/or IFR standards.
  

PSA Data Collection

• Prepare and submit quarterly reports compiling information received about all incidents and allegations of sexual abuse and sexual harassment that occurred during that quarter. The report also includes details related to ongoing investigations and other pending cases.
• Prepare and submit annual reports detailing aggregate incident-based sexual abuse and sexual harassment data, including the number of reported sexual abuse and sexual harassment allegations determined to be substantiated, unsubstantiated, unfounded, or for which an investigation is ongoing.
• Ensures that client records associated with claims of sexual abuse and sexual harassment are maintained in accordance with agency, State and Federal regulations. This includes but is not limited to including incident reports, investigative reports, offender information, case disposition, medical and counseling evaluation findings, and recommendations for post-release treatment and/or counseling.
• Utilizes data gathered during audit processes as well as quarterly and annual ORR data reports to identify program trends related to sexual abuse and harassment response. Provides ongoing feedback and data to program leadership and ORR related to effective sexual abuse and harassment response methods, including areas identified for improvement.

Formal Concerns and Grievances:

• Open cases to track any formal concerns received from the Caminos program. Oversee gathering of due diligence, delegate and/or directly conduct interviews and statement collection, and generally keep open cases moving forward to conclusion. Ensure tasks and follow-ups are documented and completed.
• Participate in discovery processes by conducting youth interviews, gathering youth statements, and reviewing video footage as needed.
• Review and maintain client grievances, ensuring timely response and resolution is executed in collaboration with Program leadership. Provides oversight to the grievance process to ensure resolution and response are documented properly and all aspects of the process meet State and Federal regulations.

Database and Reports:

• Monitor the entry of data into required agency and federal databases. Ensure other staff roles are entering data in accordance with regulatory timelines and any catch-up data entry projects are completed.
• Compile and distribute reports as scheduled that include, but are not limited to, capacity, SIR, restraint, annual and quarterly outcomes, survey summary, and licensing reports.
• Ensure all services both rendered and owed to clients are entered into required databases appropriately and accurately.
• Translate data from reports into Everstand’s company dashboard tool.
• Interpret ad hoc requests for data into search criteria and create visual displays that meet the needs of the initial data request.
• Provide technical assistance on Quality Improvement to administrative and management staff.
• Attend team and program meetings regularly to review statistical data with care team staff.
• Develop reports and presentations to present data to various organization teams and leadership committees.

Audits and Chart Management:

• Conduct at least monthly physical assessments of classroom and living unit spaces to ensure regulatory and policy compliance. Document findings and communicate necessary corrective actions to program leadership.
• Ensure at least quarterly client charts meet all internal, regulatory, licensing, and accreditation standards, especially with regards to notes, completion date, signatures, and documentation. Document findings and communicate necessary corrective actions to program and department leadership.
• Complete at least quarterly personnel and training file audits to ensure compliance with all internal, regulatory, licensing and accreditation standards, especially with regards to background clearances and training requirements. Document findings and communicate necessary corrective actions to program and department leadership.
• Conduct preliminary analysis of audit results to identify root cause. If needed following this analysis, assist department teams in the development of a Corrective Action Plan to be reviewed by the QI department leadership.
• Provide federal oversight and other regulatory bodies access to Cx360 via a guided review during audits of charts and records.

Surveys:

• Maintain mechanisms for stakeholder feedback for the Caminos Program. This includes, but is not limited to, surveys focused on employees, clients, families of clients, and other stakeholders.
• Work with the QI department to code in surveys within the Survey Monkey platform to meet the Caminos QI needs.
• Pull data from Survey Monkey and other survey mechanisms into reports as needed.
• Analyze results to identify focus areas for improvements.

Electronic Health Record (EHR) Implementation Project:

• Complete the training to become a certified EHR super user.
• Respond to staff-generated tickets such as but not limited to password resets, permissions, and errors in functionality.
• Create and generate reports from the EHR.
• Create and update existing EHR forms.
• Create new user accounts for relevant new hire staff and disable unused accounts.
• Provide training for new hires including account setup and login to the EHR online software, Cx360.

Non-Essential Functions:

• Assist with responding to federal records requests as needed.
• Assist with documentation and status reporting on non-PSA Corrective Action Plan (CAP) items as needed.
• Escalate problematic tickets using the online Jira platform and coordinate with the external EHR team to find a resolution.
• Participate in scenario and functionality testing for the EHR system. Report bugs and errors to QI Manager for review.
• Assist in trainings throughout the organization.
• Run reports on formal concerns and client grievances to look for patterns.
• Assist with document retention and scanning projects generally as needed.

Competencies:

• Analysis of Data
• Attention to Detail
• Attitude towards Honesty
• Conceptual Thinking
• Following Directions
• Handling Stress
• Meeting Standards
• Organized Workplace
• Personal Accountability
• Quality Orientation
• Ability to Resolve Problems
• Exercises Good Judgment
• Prioritization
• Project Coordination
• Discretion in Handling Responsibilities
• Navigating Web-Based Data Systems and Portals
• Learning New Technology (hardware and software)

Supervisory Responsibility:

N/A

Work Environment:

This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, tablets and smartphones, photocopiers, scanners, filing cabinets and fax machines.

Due to the nature of residential and school living environments, there may be times you experience conditions in which challenging behavior can be exhibited from our youth to include but not limited to physical agitation, physical violence and/or emotional outburst.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work:

This is a full-time position. Days and hours of work are Monday through Friday, 8:30 a.m. to 5 p.m. This position regularly requires flexible hours to include some evenings.
Eligible for flex schedule. This position is not essential during inclement weather.

Travel:

Weekly expectation associated with travel included between program locations in WV and occasional travel to other organizational locations. Travel is anticipated more on a quarterly basis. A company vehicle will be provided as needed.

Required Education and Experience:

• Bachelor’s degree in behavioral sciences, human services, or social service fields. 

OR

• Bachelor's degree in business administration or management AND At least 1 year of experience working with child welfare standards, best practices, or quality assurance or compliance.

Preferred Education and Experience:

• A master’s degree and four years’ experience in the field.

Experience with state licensure, federal grant management and national accreditation or familiarity with these processes.

• 3 years documented, progressively responsible experience in the field of child and family services and/or behavioral health care.
• Experience with funding regulations, standards and requirements.
• Knowledge of Maryland, Pennsylvania and West Virginia residential care regulatory requirements a plus.
• Spanish speaking and reading preferred but not required.

Additional Eligibility Qualifications:

• Demonstrates knowledge of and familiarity with both Everstand and Office of Refugee Resettlement Policy and Procedures relating to the care and supervision of Unaccompanied Children. This includes knowledge of legal background and authority governing the practice as related to working with Unaccompanied Children.
• Demonstrates familiarity and understanding of medical compliance and data entry standards.
• Must be able to self-manage and prioritize daily schedules, work effectively in a collaborative style with internal and external stakeholders, team members, managers and executives.
• Ability to read/understand vendor training materials.
• Excellent writing skills. Able to effectively communicate with individuals at various levels of computer skill.
• Ability to lead meetings, prioritize, resolve conflicts, maintain issues lists and manage a project plan required.
• Strong communication and follow-up skills required.
• Proven ability to manage multiple projects, priorities, meet deadlines, multi-task, and think creatively.
• Solid Windows 10 computer proficiency.
• Advanced knowledge of Microsoft Word is required (e.g. mail merge, creating a live table of contents).
• Advanced knowledge of Microsoft Excel is required (e.g. pivot tables, graphs, filters, vlookups).
• Proficiency in Microsoft Outlook and PowerPoint.
• Ability to keep an electronic calendar (Outlook) and task list (Asana.com) is required.
• Ability to obtain and maintain certification in CPR/First Aid.
• Ability to demonstrate the possession of a valid driver’s license prior to employment and ability to maintain the license and operate a motor vehicle thereafter.
• Ability to pass CPS/UII background check both prior to employment and per the schedule outlined by HR thereafter.
• Ability to pass a Tuberculosis Test both prior to employment and per the schedule outlined by HR thereafter.
• Ability to pass a work-readiness physical performed by a certified medical professional both prior to employment and per the schedule outlined by HR thereafter.
• Ability to pass a Federal and State Fingerprinting Background Check both prior to employment and per the schedule outlined by HR thereafter.
• Ability to pass a drug screen via urinalysis both prior to employment and randomly thereafter.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Everstand is an equal-opportunity employer. We celebrate diversity and encourage all qualified applicants to apply, regardless of background, identity, or lived experience.

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