Director of Quality Assurance

Career Details:


Hours: Regular Full-Time

Shift: First

Weekend Required: No

Location: Nottingham

City: Jamesville

Openings: 1


The Senior Quality Assurance Analyst directs, analyzes, researches and understands critical data points to improve clinical competencies and quality assurance programs of Loretto’s adult care facility programs. Provides guidance, support, communication and coordination of clinical programs, goals, standards and applications. Reviews all quality data to ensure accuracy and assist with the development of quality improvement plans. Generates reporting that enables in the review of data, ensuring that leaders can make timely decisions to meet all DOH and Onondaga County Health Department regulations and guidelines.

  • Bachelor of Science in Health Care or related field.
  • Combination of a minimum of five (5) years related experience with QA responsibilities in a health care setting.
  • Working knowledge and understanding of New York State Department of Health regulations, Part(s) 485,486, 487, 488 and 489, that regulate Adult Homes, Enriched Housing and Assisted Living Programs.
  • Proven data and information management skills with a working knowledge of computer programs including spreadsheets, word processing, etc.
  • Demonstrated ability to work with mathematical concepts and an overall basic understanding of statistics as well as ability to work as part of the team.
  • Manages the Program’s performance improvement and quality improvement activities to enhance the quality and safety of resident care; provides analysis of performance improvement activities and the program’s benchmarks for the provision of high quality, cost effective care to meet/exceed regulatory requirements. Annually reviews and revises QAPI plan including quality indicators, worksheets and monitoring tools; designs data collection procedures, methods and systems to track and validate findings; coordinates development of Corrective Action Plans for negative trends with a goal to improve quality process and quality of resident care.


  • Works closely with all disciplines to develop discipline specific indicators to enhance resident/ family satisfaction and quality outcomes; provides staff education on QA processes and outcomes. Coordinates/assists all departments with the evaluation of services provided as evidenced by indicators; facilitates and enhances communication between involved departments with regular meetings.


  • Assists Administrators and Housing Staff in identification/investigations and follow up of problematic events.


  • Oversees and manages the Customer Service Department, providing support and guidance. Reviews and distributes corporate customer surveys to multiple entities within the Loretto corporation.


  • Ensures that resident/family calls are completed and admission and discharge surveys are sent to appropriate individuals.


  • Monitors progress on any open QA issues; assists in policy and procedure development and revisions as appropriate based upon QA trends.


  • Creates policies and procedures for the Loretto Housing Department of Health Policy and Procedure manual that includes a policy and procedure for all regulations for Adult Homes, Enriched Housing and Assisted Living Programs. Manages and oversees annual review and revisions of policy and procedures for the manual. Updates and disseminates policies and procedures as needed for Department of Health Survey Plan(s) of Corrections.


  • Assists staff with review of Department of Health Statement of Deficiencies for possible Inspection Review Process.


  • Assists with writing and implementation of survey Plans of Correction, provides interpretation and support with New York State Department of Health regulatory requirements to ensure compliance.


  • Attends quarterly site and Loretto Adult Community/Heritage Apartment Home Care’s QA meetings with site administrators and the Director of Clinical Services. Collects and reviews all data from QAPI committee members; reviews the QAPI plans for Housing and the Licensed Agency on an annual basis.


  • Responsible for the preparation of the agenda for the quarterly Corporate Program Standards Committee. Assists with the collection of committee meeting’s material for the construction of meeting packets for the board members.


  • Manages the organization of the Assisted Living Program’s preparation of a possible Office of the Medicaid Inspector General audit; supervises and assists with the arrangement of Resident files to mitigate Loretto’s exposure to fines resulting in non-compliance with Medicaid requirements.


  • Responsible for responding to the Loretto complaint hotline calls; serves as the Housing Compliance Coordinator. Available to respond to serious complaint allegations 24/7 and responsible to direct the critical calls to appropriate staff for investigation.


  • Serves as Housing’s Corporate Compliance Officer. Attends corporate compliance meetings monthly/quarterly to review existing and create new policies and procedures relative to the corporate compliance plan.


  • Responsible for promoting and fostering compliance in the workplace. Communicates expectations to employees regarding compliance-oriented behavior in the workplace. Models and adheres to the mission and philosophy of Housing and the Loretto Corporation; responsible for complying with all applicable compliance laws and regulations, as well as all program and corporate compliance policies and the code of conduct. Demonstrates adherence to all compliance policies and procedures and the code of conduct.


  • Models and promotes service excellence by developing and maintaining positive respectful relationships with all customers, internal and external; ensures the highest quality of care by performing responsibilities according to the highest professional standards.


  • Practices safety awareness, reports or corrects any possible safety/environment issues to appropriate individual, and adheres to all safety policies and procedures.


  • Regularly attends administrator’s meetings. Reports on projects, department and policy changes, etc. to promote communication among management team.
Apply Now Back to Listings

Share this page with a friend

Return To Top