This role administers Avamere’s Special Focus Facility (SFF) program to support facilities designated as SFF by the Center for Medicare & Medicaid Services (CMS). The SFF Director will oversee the distribution and utilization of necessary supports, services and resources from Avamere’s existing programs as well as opportunities to leverage knowledge, skills, abilities, services and systems such as external consultants and quality assurance professionals. The SSF Director will plan, organize and implement program and process improvements, monitoring performance of a designated facility.

Essential Duties and Job Responsibilities

• Develop required policies and general operating procedures which support the Special Focus Facility Compliance Program.

• Develop a Special Focus Compliance Plan for the facility to ensure the facility reaches the levels required for graduation from SSF status as soon as possible.

• Coordinate with Avamere regional and corporate compliance support for needed training and systems implementation. Director requests will receive the highest level of priority from all company departments normally responsible for meeting our facilities’ needs.

• Utilize Non-Avamere compliance consultants and training resources; exercise independent authority to determine and implement, based on a needs/capacity analysis, any outside consultative services which might support the facilities efforts to improve compliance toward graduation from the SFF program.

• Conduct evaluations of key facility management staff including the Administrator and Director of Nursing, make recommendations for hire, retention, release, training, and special monitoring, to ensure program improvement focus is appropriately directed to ensure competent staff is provided to serve the facility resident population.

• Conduct Root Cause Analysis of issues which may have contributed to the designation of the facility as a SFF, and which may continue to be barriers to graduation from SFF status; implement any needed corrections in process and/or structure which they may deem necessary. Collaborate with company managers and departments in the process of conducting Root Cause Analysis; submit Root Cause Analysis reports to the President and executive team for potential company-wide interventions.

• Review and update the Facility Assessment to ensure that it reflects the current status and needs of the facility as required under F 838 to ensure the facility has a strong support compliance plan to care for the needs of the resident population.

• Retain approval authority over any proposed changes in staffing and/or other budget levels; direct the implementation of any supplemental staffing as deemed necessary based on a needs analysis.

• Assess risk management system and support existing processes; implement substitute or additional processes as needed to ensure resident safety and freedom from abuse or neglect.

• Determine Admission Criteria and Capacity based on the Facility Assessment and regular reviews of current clinical and operational capacity; set admission restrictions, admission criteria, and census levels, as deemed necessary to ensure that the facility can safely provide care for residents. This authority supercedes budgetary expectations which might have been determined based on annual program development expectations.

• Prepare monthly written progress reports presented to:

o Avamere President – for review and comment

o RCS Field Office Manager – as demonstration of progress or issues.

o Other interested persons or agencies as appropriate

• Serve as the facility Grievance Officer per F-585, and report summary grievance information to the Resident Council on a monthly basis.

• Review, approve, revise and implement any policy deemed necessary to support resident care and safety and progress toward SFF graduation.

Minimum Requirements

• Bachelor’s degree in Healthcare Administration, Compliance or a related field; 10 years of prior employment experience in residential healthcare setting including Five years of experience as a longterm care facility Administrator or significantly similar role. An equivalent combination of education and experience may be considered.

Preferred Qualifications

• Advance degree in Business or healthcare administration

• Previous leadership experience in a multistate residential health care setting.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Sitting/ for extended periods of time.

• Lifting and transporting of moderately heavy objects, such as computers and peripherals.

• Physically able to participate in sessions, presentations, and meetings.

• Some travel may be required for the purpose of meeting with vendors, suppliers, service providers, or offsite contractors.

• Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.

• Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.

• Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.

• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.

• May be subject to the handling of and exposure to hazardous chemicals.