The QA Manager oversees the quality of charting and QUAPI program by managing chart audits—making sure care is safe, effective, patient-centered and compliant with regulations.
Key Roles & Responsibilities
1. QAPI Program Oversight
Manage and implement the hospice QAPI plan
Identify areas for improvement using data (falls, infections, hospitalizations, etc.)
Lead performance improvement projects (PIPs)
Track and report outcomes to leadership
2. Regulatory Compliance
Ensure compliance with:
Medicare Conditions of Participation
State regulations
Prepare for surveys (CMS and state)
Conduct mock surveys and audits
Maintain readiness at all times (survey-ready culture)
3. Clinical Chart Audits
Review patient charts for:
Proper documentation
Eligibility (LCD guidelines)
Timeliness (admissions, recertifications, visits)
Identify trends in documentation deficiencies
Provide feedback to clinical staff
4. Education & Staff Training
Educate staff on:
Documentation standards
Regulatory updates
Quality initiatives
Conduct in-services and competency training
Collaborate with clinical leadership (DPCS)
5. Incident & Risk Management
Oversee reporting and investigation of:
Falls
Medication errors
Patient/family complaints
Perform root cause analysis (RCA)
Implement corrective action plans
6. Performance Metrics & Data Tracking
Monitor key hospice quality indicators:
CAHPS Hospice Survey scores
Hospitalizations/revocations
Pain and symptom management effectiveness
Analyze trends and present reports to leadership/IDT
7. Policy & Procedure Management
Develop and update hospice policies/procedures
Ensure policies align with current regulations
Assist departments in implementing policies correctly
8. Interdisciplinary Team (IDT) Collaboration
Attend IDT meetings to ensure:
Compliance with care planning
Documentation supports hospice eligibility
Support clinicians with quality improvement strategies
9. Survey & Audit Response
Lead response to:
State/CMS survey findings
ADRs (Additional Documentation Requests)
Create Plans of Correction (POCs)
Ensure follow-through on deficiencies
Key Skills Needed
Strong knowledge of hospice regulations (CMS, state)