Quality Assurance & Compliance Coordinator

About the role

The Quality Assurance & Compliance Coordinator plays a crucial role in ensuring that MBK Senior Living adheres to all regulatory and accreditation standards. This position is vital for maintaining a safe and secure environment, conducting regular facility inspections, and promoting a culture of continuous quality improvement.

Responsibilities

• Lead the execution of the quality assurance program, verifying adherence to all regulatory mandates (federal, state, local).
• Oversee and verify daily and future staffing plans and schedules to ensure compliance with state-mandated acuity models and minimum staffing ratios.
• Maintain official accreditation status by continuously monitoring compliance with all established standards and coordinating necessary internal activities.
• Serve as a liaison for regulatory agencies and accreditation bodies, preparing for, managing, and coordinating all third-party audits, surveys, and inspections.
• Collaborate with the Executive Director and others to develop action plans to address deficiencies and ensure timely resolution.
• Maintain centralized records for all compliance and survey documentation, ensuring accurate and timely reporting of corrective actions.
• Ensure a safe and secure environment for staff, residents, and guests following established safety standards, policies, and procedures.

Quality Assurance Performance Monitoring and Risk Management

• Conduct regular facility inspections, operational site reviews, and audits to assess performance and identify areas for improvement.
• Implement and oversee data collection to establish, track, and report on Key Performance Indicators (KPIs) and trends related to quality, compliance, and resident satisfaction.
• Develop and monitor Quality Improvement Plans (QIPs) and action plans to address deficiencies and drive resolutions.
• Promote a culture of continuous improvement and quality-focused care by developing and presenting outcomes and providing actionable recommendations to leadership.
• Implement comprehensive risk-management procedures, including maintaining accurate incident logs, addressing concerns proactively, and overseeing Critical Incident Reporting and Mortality Review processes.
• Proactively investigate and resolve quality assurance concerns, complaints, and incidents to uphold a safe and supportive environment.
• Ensure accurate documentation and record-keeping to support compliance and operational effectiveness.

Training & Development

• Assess ongoing training needs and collaborate with home office to create new training, as needed.
• Conduct training programs for staff on regulatory compliance, risk management, and quality assurance, and educate employees in company policies and procedures.
• Ensure required and assigned training is completed.
• Stay current and comply with industry trends and changes in federal, state, and local regulations affecting senior living communities (assisted, independent, memory care).
• Maintain knowledge and understanding of operation’s regulatory, accreditation, and company regulations, policies, and/or procedures.

Teamwork, Communication & Leadership

• Provide detailed reports and recommendations for executive leadership on operational review findings, quality performance, and compliance status.
• Collaborate with Executive Directors, department heads, and other leadership team members to align quality initiatives with operational goals, and drive quality improvements.
• Ensure effective communication with residents, families, and staff regarding quality assurance initiatives and compliance updates.
• Act as a collaborative partner and cross-functional team member, providing temporary support and coverage across various departments (e.g., Sales, Operations) during critical periods, staff vacancies, or as requested.
• Promote a spirit of teamwork and open communication in alignment with MBK principles and core values.
• Perform other job duties or special projects as assigned or requested by Supervisor.

Education And Licenses/Certifications

• High school diploma or equivalent (GED), required.
• Must hold current State administrator’s license and maintain with required CEUs.
• College degree in Healthcare Administration, Nursing, Gerontology, or related field, a plus.

Experience Requirements

• 3+ years of prior related work experience in quality assurance, regulatory compliance, or risk management in the senior living or healthcare industry.

Required Competencies

• Stay up to date and knowledgeable about state-mandated acuity model (i.e., ABST) and state regulations.
• Proven experience managing audits, regulatory compliance, and accreditation processes.
• Strong technical and computer skills, including proficiency in Microsoft Office Suite (e.g., Word, Excel, Outlook, etc.), and experience operating standard office equipment.
• Must complete required Background clearances, health screening and provide negative TB test results within 7 days of employment (must be within the last 6 months).
• Valid state-issued driver’s license and valid insurance or reliable method of transportation.
• Excellent written and verbal communication skills, including the ability to speak, write and read English and must be comfortable with speaking in public settings, presenting to small groups and interacting with regulatory representatives.
• Able to deal tactfully and professionally at all times with personnel, residents, family members, auditors, and guests.
• Able to make sound, independent decisions when circumstances warrant, remain calm and effectively manage conflicts, stressful or emergency situations.
• Able to work independently without direct oversight and supervision.
• Present a positive and professional image.

Physical Demands & Work Environment

• Must be mobile and able to perform the physical requirements of the job, including walking, bending, kneeling, squatting, pulling, reaching overhead, and repetitive motion.
• Ability to move intermittently throughout the workday, in the community and between neighborhoods.
• Ability to lift and carry up to 50 pounds and push up to 250 pounds, as necessary.
• Ability to assist in the physical movement of residents during routine transfers and in emergency situations.

Regulatory Disclosures for Senior Living Communities with Medicaid Residents

• An “Excluded Party” is a person that the federal or state government found not eligible to provide care and services in a facility that receives Medicare or Medicaid funding.
• If employed at one of our senior living communities that receives Medicare or Medicaid funding, team members must not be considered an “Excluded Party” as defined by the U.S. Department of Health and Human Services, any state Medicaid Programs, and any additional federal and state government contract programs.
• If, as a team member, you learn that you are an Excluded Party at any time, you must present your Excluded Party notice letter to your supervisor immediately.

Other Regulatory Requirements

• If employed at one of our senior living communities, team members must continually comply with certain laws and regulations that impact the company, including, but not limited to, as applicable, state licensing regulations, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Resident Rights as defined by the U.S. Department of Health and Human Services, and any other federal or state laws relating to team members’ professional licenses.

HIPAA Disclosure

• All Team Members prior to commencing employment and once employed must not be considered an “Excluded Party” as defined by the Medicare and state Medicaid Programs as well as other federal and state government contract programs.
• If as an associate you learn you are an Excluded Party, you must present your Excluded Party notice letter to your supervisor immediately.
• An Excluded Party is a person that the federal or state government found not eligible to provide care and services in a Community that receives Medicare or Medicaid funding.
• In addition, at all times, during your employment, all associates must be in compliance with certain laws and regulations that affect the company, including but not limited to Resident Rights, HIPAA, State licensing regulations, and those laws relating you an associates’ professional license.