Medical Quality Improvement Reviewer​/CSU​/2346​/NP

Medical Quality Improvement Reviewer/CSU/2346/NP

Location:

Bartow/Lakeland, FL.

The Quality Improvement Reviewer is responsible for monitoring, evaluating, and improving the quality of clinical and operational services within Peace River Center's Crisis Stabilization Units (CSUs). This position conducts ongoing audits of medical records, documentation, and unit operations to ensure compliance with agency policies, state and federal regulations, accreditation standards, and best clinical practices. The Quality Improvement Reviewer identifies opportunities for process improvement, assists with corrective action planning, investigates incidents and complaints, monitors regulatory compliance, and collaborates with leadership to promote a culture of quality, patient safety, and continuous performance improvement.

This position serves as a resource to clinical and administrative staff, providing education, feedback, and support to enhance documentation accuracy, ensure regulatory compliance, and improve patient outcomes.

In the performance of their respective tasks and duties, all employees are expected to conform to the following:

• Adhere to all PRC policies and Code of Conduct standards and always exhibit all PRC's Core Values.
• Perform quality work within deadlines with or without direct supervision.
• Interact professionally with other employees, customers, and vendors.
• Work independently, while understanding the necessity for communicating and coordinating work efforts with other employees and organizations, as required.
• Ability to arrive/report to work on time and ready to work.
• Ability to abide by principles of EEO compliance and a workplace of dignity and respect.
• Ability to work cooperatively in a group/team setting.
• Ability to show respect and professionally communicate with others.
• Ability to take guidance and direction from supervisors.
• Ability to report to work with clean hygiene.
• Ability to adhere to Company/Program dress code standards.
• Serve as the Quality Improvement liaison for inpatient units; collaborate with cross-functional teams to ensure compliance and continuous improvement.
• Assists in evaluation of data from audits and identification of quality improvement opportunities.
• Participates in Quality Improvement initiatives in assigned roles as delegated.
• Run daily ObservSMART Reports and follow up with management in a timely manner.
• Perform daily chart reviews using standardized audit tool. This will address requirements including, but not limited to:
  • Legal guardianship identified and documented.
• Petitions filed within required time frames
• Assessments completed within required time frames, including family involvement (if allowed by client)
• All health needs addressed appropriately and timely.
• Orders documented appropriately (admission, SANDR)
• Required consents/notifications completed and signed.
• Client's home meds are properly documented and stored.
• Medications are prescribed properly and appropriately administered.
• Special orders are documented and executed properly (communication restrictions, diet needs, labs, etc.).
• Treatment plans completed within 24 hours & updated every 5 days.
• Treatment plans are individualized and include family involvement (if allowed by client)
• Progress notes match treatment goals
• Discharge planning is completed properly, including appropriate referrals and family involvement (if allowed by client)
• Clients are provided with appropriate follow-up appointments.
• Random direct observation of unit operations
• Monthly checks of emergency equipment (AED, oxygen, Emergency Drug Kit)
• Conduct Emergency Drills and Training
• Serve as Infection Control liaison for the units.
• Assist with investigation and root cause analysis of reported incidents and complaints, including video reviews of seclusion/restraints; allegations of abuse, neglect, or exploitation; and medical emergencies.
• Work collaboratively with HR and department leadership to ensure required regulatory and agency training requirements are current.
• Assist with data preparation for Quality Committees.
• Monitor compliance with DCF, AHCA, CMS, Joint Commission (if applicable), and agency standards.
• Track, trend, and analyze quality indicators and prepare reports for leadership.
• Assist departments with developing and implementing corrective action plans following audits or regulatory findings.
• Conduct follow-up reviews to ensure corrective actions have been successfully implemented.
• Participate in preparation for internal and external surveys, audits, and accreditation reviews.
• Maintain confidentiality of protected health information (PHI) in accordance with HIPAA regulations.
• Provide education and feedback to staff regarding documentation deficiencies and regulatory requirements.
• Collaborate with Nursing, Medical, Clinical, and Operations leadership to improve patient care processes.
• Perform other duties as assigned in support of the Quality Improvement Program.

Graduate of an accredited school of practical or professional nursing. Current, active, and…