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Overview

The Regulatory Compliance Advisor is responsible for overseeing Regulatory

compliance and the Quality Review process that supports compliance to state and federal

regulations, as well as GHC policies and procedures. He/she will oversee the process to

ensure quality reviews will be conducted at each center a minimum of annually. This

role will collaborate with Market Advisors, Market Clinical Advisors, Center Leadership,

food and nutrition services, rehab services, property management, and others as needed,

to ensure their involvement in the process.

Responsibilities

1. Collaborate with Market teams to create an overall survey improvement plan as

well as individual center survey improvement plans to include focus on past survey

history, Quality Review results, leadership training needs and a roadmap for

completion of CEP’s

2. Establish priority centers based on Health Inspection ratings, SFF status,

Government oversight, Special licenses, or other special circumstances.

3. Participate in Quality Reviews in the Market. Ensure the Quality Review is

scheduled no less than 90 days prior to the survey window opening.

4. Provide support during all Health inspections on site or remotely during the survey,

ensure plan of correction is submitted timely and validate readiness for revisit.

5. Collaborate with Market Advisor, Clinical Advisor or other designated Market team

members to ensure coordination and appropriate selection of team members, sample

selection, and informing the Center of the date and items needed for the Quality Review.

6. Will ensure the approved Quality Review process will be followed accordingly and

Critical Element Pathways are utilized. Support Market team in assessing center staff’s

ability to identify issues.

7. Oversee that coaching is part of Quality Review process for Center staff in survey

management to help them build confidence and be well prepared for the survey.

8. Ensures process in place for an informal exit review with the Center staff so center may

begin immediate correction of identified issues.

9. Ensure process is in place for Quality Review findings report is provided to the

Administrator within 10 days of the Quality Review Collaborate with others to identify

resources/processes needed to assure action plan has been completed prior to survey

Schedule validation visit.

9.Provide feedback to the National team to ensure the Quality Review process remains current

with changing regulations.

10.Analyze effectiveness of Quality Review process by comparing Quality Review and actual

survey findings.

11.Maintain knowledge of state and federal long-term care regulations.

12.Be a resource for federal and state regulatory changes and inform Market team and Center

leaders of regulatory changes.

13.Ensure processes in place to evaluate Center staff ability to manage the survey process and

interact with surveyors.

14.Prepare and present training sessions for Market related to survey process, regulatory

guidelines and any other related issue identified in coordination with the Market/National team.

15.Provide feedback regarding findings and need for changes to policies, programs, or training.

16. Ensure survey information has been entered into the regulatory tracking system.

17.Works with Market and National team as appropriate to:

a. Respond to critical events

b. Support clinical and operations practice

c. Leadership and direction on key clinical projects;

18. Establish relationships with regional CMS staff and state survey agencies

19.. Identify SFF Centers, SFF candidate centers, Low Health Inspection Star ratings

and implement Focus Center calls

20. Collaborates with the Market Team to understand and improve the quality outcomes for

residents, families and staff at designated centers.

22. Serve as resource expert on available resources including but not limited to Team TSI,

Compliance Store, AAPCN, Care Data Hub., QSEP

22. Meet with New NHA/DON’s to review survey history and educate on Genesis tools and

resources related to Regulatory compliance.

23.Other duties as assigned.

COMPLIANCE:

1. Complies with and promotes adherence to applicable legal requirements, standards,

policies and procedures including but not limited those within the Compliance and Ethics

Program, Standard/Code of Conduct, Federal False Claims Act and HIPAA.

2. Provides leadership and support for the Compliance and Ethics Program within

management area.

3. Ensures timely and accurate reporting and responses to compliance-related issues and

monitors the implementation of corrective action plans related to such issues.

4. Ensures that staff participates in orientation and training programs including but not

limited to all required compliance courses and relevant policies and procedures, and that

such training is properly documented. Participates in compliance and other required

training programs.

Open lines of communication regarding compliance issues within

management

area and access to the Integrity Line and ensures that retaliation against staff who report

suspected incidences of non-compliance does not occur. Promptly reports concerns and

suspected incidences of non-compliance to supervisor, Compliance Liaison or to the

Compliance Officer via the Integrity Hotline.

6. Participates in monitoring and auditing activities and investigations, and implementing

quality assurance and performance improvement processes, as required.

7. Completes performance reviews and determines compensation and promotions based

on the accomplishment of established standards that promote adherence to compliance

and

quality standards.

Qualifications

1. Three to five years of experience.

in the long-term care industry with preferred experience in regulatory compliance.

2. Must have an understanding of long-term care guidelines and regulations and be

knowledgeable in the state survey process.

3. Must be proficient in observation of both resident care and the Center

environment, and reviewing charts and other regulatory documentation requirements.

4. Must be experienced in interpreting the regulation and associated F-tags and

applying them to the findings.

5. Must be knowledgeable of the CMS enforcement process related to surveys, i.e.,

CMPs, DPNAs, etc.

6. Must be able to travel extensively.

Posted Salary Range

USD $145,000.00 - USD $160,000.00 /Yr.

Genesis HealthCare, Inc. and all affiliated entities (collectively “Genesis”) has a strong commitment to diversity that is fully supported and practiced by our officers and leadership team. Genesis provides equal employment opportunities to all employees and applicants for employment without regard to actual or perceived race, color, religion, gender, gender expression, gender identity, sex, sexual orientation, HIV status, national origin, age, disability, marital status, pregnancy, ancestry, citizenship, genetic information, amnesty, military status or status as protected veterans, or any other legally protected characteristic. Genesis is an Affirmative Action and Equal Opportunity Employer and our goal is to foster an inclusive and accessible workplace free from discrimination and harassment where everyone has equal opportunities to succeed.