Compliance and Quality Coordinator

Position Summary

The Compliance and Quality Coordinator is responsible for supporting ACSA Home
Health's compliance, quality assurance, regulatory readiness, and brand management
activities. This position helps ensure that agency operations, staff records, client/patient
records, policies, procedures, marketing materials, and public communications are
consistent with applicable requirements and ACSA Home Health standards.

The Coordinator works closely with Administration, Human Resources, Clinical,
Scheduling, and other departments to identify compliance concerns, monitor quality,
maintain survey readiness, track corrective actions, and promote consistent agency
practices.

The position also oversees day-to-day brand management to ensure ACSA Home Health is
represented professionally and consistently across documents, marketing materials,
social media, recruitment materials, community outreach, and other communications.

Essential Areas of Responsibility

1. Compliance Monitoring
   • Assist with monitoring agency compliance with applicable federal, state, payer,
   accreditation, and internal requirements.
   • Review agency operations for compliance with established policies and procedures.
   • Maintain compliance calendars, tracking systems, and required documentation.
   • Monitor expiration dates and renewal requirements for licenses, certifications,
   insurance, clearances, training, and other required documents.
   • Identify missing, expired, or incomplete documentation and communicate
   deficiencies to the appropriate department.
   • Track compliance concerns through resolution.
   • Assist leadership with implementation of new or revised regulatory requirements.
   • Maintain organized compliance records for audits, surveys, and internal reviews.
   • Immediately report significant compliance concerns to the Administrator or
   designated leadership.
   • Facilitate QAPI meetings quarterly with all internal staff
2. Quality Assurance and Performance Improvement
   • Support ACSA Home Health's Quality Assurance and Performance Improvement
   activities.
   • Conduct routine audits of client/patient and staff records.
   • Review documentation for completeness, accuracy, timeliness, and compliance.
   • Track quality indicators, trends, deficiencies, complaints, incidents, and corrective
   actions.
   • Assist with identifying opportunities for operational and quality improvement.
   • Prepare quality reports for leadership review.
   • Follow up with departments regarding identified deficiencies.
   • Monitor corrective action plans to ensure required corrections are completed.
   • Assist with quality improvement projects and measure whether implemented
   changes are effective.
3. Staff File Compliance
   • Conduct scheduled audits of staff files.
   • Verify required licenses, certifications, background checks, clearances, physicals,
   TB documentation, competency documentation, training, and other required
   records.
   • Maintain a tracking system for documents approaching expiration.
   • Notify Human Resources and leadership of missing or expired documentation.
   • Follow up until deficiencies are corrected.
   • Assist with ensuring staff meet initial and annual training and competency
   requirements applicable to their positions.
4. Client/Patient Record Auditing
   • Perform periodic audits of client and patient records.
   • Review records for required assessments, plans of care/service plans,
   authorizations, orders, visit documentation, signatures, and other required
   documentation.
   • Identify missing, inconsistent, late, or incomplete documentation.
   • Communicate findings with responsible staff or departments.
   • Track corrections and follow-up activities.
   • Identify recurring documentation problems and recommend additional training or
   process improvements.
5. Survey and Audit Readiness
   • Maintain agency readiness for licensing surveys, payer audits, regulatory reviews,
   and other external inspections.
   • Assist with organizing requested documentation before and during surveys.
   • Conduct routine internal readiness audits.
   • Maintain required compliance and survey documentation in an organized and
   accessible manner.
   • Assist leadership with responses to survey findings.
   • Track Plans of Correction and other corrective actions through completion.
   • Maintain documentation demonstrating that corrective actions were implemented.
6. Policy and Procedure Management
   • Maintain the agency's policy and procedure library.
   • Track policy review and revision dates.
   • Coordinate scheduled policy reviews with leadership.
   • Assist with updating policies when regulations, agency operations, or requirements
   change.
   • Ensure obsolete policies are appropriately archived, and current versions are
   available to staff.
   • Maintain documentation of staff acknowledgment and training when required
   following significant policy changes.
7. Incident, Complaint, and Risk Tracking
   • Maintain logs of complaints, incidents, grievances, and other quality or compliance
   concerns.
   • Ensure issues are forwarded to the appropriate leadership personnel for
   investigation.
   • Track investigations and corrective actions through completion.
   • Monitor recurring issues and identify trends.
   • Assist leadership in determining whether additional policies, education, or
   operational changes are necessary.
   • Maintain confidentiality of complaint, investigation, and compliance information.
8. Training and Education Support
   • Assist with coordinating required compliance and quality training.
   • Track completion of mandatory training.
   • Help develop staff education related to compliance deficiencies or audit findings.
   • Provide reminders regarding regulatory and agency requirements.
   • Work with Human Resources and leadership to address recurring staff compliance
   concerns.
   • Assist with annual compliance, HIPAA/privacy, documentation, quality, and other
   required training initiatives.

Brand Management Responsibilities

The Compliance and Quality Coordinator will also serve as a brand management
resource for ACSA Home Health, helping ensure that the agency maintains a consistent,
professional, and recognizable public image.

Responsibilities include:

• Monitor appropriate use of the ACSA Home Health name, logo, colors, tagline, and
approved branding.
• Review agency documents for consistent branding and professional presentation.
• Maintain approved templates for forms, letters, presentations, flyers, recruitment
materials, and other agency documents.
• Review marketing materials before publication or distribution.
• Assist with maintaining consistency across the agency website, social media,
printed materials, digital communications, and community outreach materials.
• Coordinate creation and scheduling of approved social media and agency
awareness content.
• Support recruitment branding and caregiver/staff recruitment campaigns.
• Assist with community outreach materials and agency promotional initiatives.
• Ensure marketing communications accurately represent the services ACSA Home
Health provides.
• Review public-facing materials for potential privacy, compliance, confidentiality, or
regulatory concerns.
• Ensure photographs, testimonials, client/patient information, or staff information
are not used publicly without appropriate authorization when required.
• Maintain organized electronic files of approved logos, templates, photographs,
advertisements, flyers, and other brand assets.
• Monitor outdated agency materials and coordinate their replacement.
• Work with leadership to maintain a consistent professional image for ACSA Home
Health.

Reporting and Tracking Responsibilities

The Compliance and Quality Coordinator will maintain appropriate tracking systems for:
• Staff file deficiencies
• Expiring staff documentation
• Client/patient record audits
• Compliance audits
• Complaints and grievances
• Incidents
• Corrective actions
• Plans of Correction
• Policy review dates
• Mandatory staff training
• Quality improvement initiatives
• Survey readiness activities
• Brand and marketing projects

The Coordinator will provide routine reports to the Administrator or designated leadership
regarding outstanding deficiencies, trends, deadlines, and areas requiring management
attention.

Qualifications

Required:

• High school diploma or equivalent.
• Strong organizational and documentation skills.
• Strong attention to detail.
• Ability to maintain confidential information.
• Ability to manage multiple deadlines and follow-up activities.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office, electronic records, spreadsheets, email, and webbased business systems.
• Ability to review records carefully and identify missing or inconsistent information.

Preferred:

• Associate or bachelor’s degree in healthcare administration, business
administration, quality management, compliance, communications, marketing, or a
related field.
• Experience working in home health, home care, healthcare, compliance, quality
assurance, or healthcare administration.
• Experience with electronic medical record or home care software.
• Experience with auditing, regulatory compliance, or quality improvement.
• Experience with social media, marketing, graphic content, or brand management.

Core Competencies

The successful candidate should demonstrate:
• Exceptional attention to detail
• Organization and follow-through
• Professional judgment
• Confidentiality
• Regulatory awareness
• Analytical thinking
• Problem-solving ability
• Written communication skills
• Documentation accuracy
• Time management
• Ability to identify trends and recurring problems
• Ability to work across multiple departments
• Professional communication with staff and leadership
• Consistency in maintaining agency branding and professional standards

Authority and Accountability

The Compliance and Quality Coordinator is responsible for identifying, documenting,
tracking, and reporting compliance and quality concerns. The Coordinator may request
missing documentation and follow up with staff regarding outstanding compliance
requirements within the authority established by ACSA Home Health.
Significant compliance violations, suspected fraud or abuse, patient/client safety
concerns, privacy breaches, regulatory concerns, or repeated failure to correct identified
deficiencies must be immediately escalated to the Administrator or appropriate member of
leadership.
The Compliance and Quality Coordinator does not independently make clinical decisions
or final disciplinary decisions unless such authority has been specifically delegated by
agency leadership.

Performance Expectations

Performance will be evaluated based on:

• Accuracy and completeness of audits
• Timely identification of compliance deficiencies
• Timely follow-up and closure of deficiencies
• Staff and client/patient record compliance
• Survey and audit readiness
• Accuracy of compliance tracking systems
• Completion of quality improvement activities
• Timeliness of required reports
• Policy management and organization
• Effectiveness of communication with departments
• Consistency and professionalism of ACSA Home Health branding
• Ability to maintain confidentiality and professional standards