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.
