The Role

Designs, maintains, and evaluates the internal investigative and quality management program to ensure consistency of delivered services, compliance with legislation, directives, policies, procedures, clinical practice, and staff training.

Duties/Responsibilities

• Ensures service delivery and operations meet regulatory compliance requirements and person-centred service philosophy.
• Supervises Quality and Risk Coordinator, RAI team, Staff Education Coordinator, and Quality RPNs.
• Performs and manages internal investigations in response to complaints and quality assurance concerns regarding delivery of resident care services and professional practice standards. Obtains, organizes, and analyses pertinent records and information as evidence (e.g., resident care documentation, call reports, security footage).
• Develops and implements quality improvement/best practice initiatives, including leading/supporting in accreditation program teams, managing the continuous quality improvement program, and conducting program reviews.
• Supports compliance management program in collaboration with the Manager, Resident Care. Responds to concerns related to compliance, develops action plans, and supports compliance assurance.
• Collaborates with Labour Relations to design, maintain, and evaluate the internal investigative and quality review program. Monitors and prepares reports on the status of investigations; presents to senior management; and makes recommendations to improve/revise the program. Assists senior management in determining training requirements and provides investigative training to supervisors, as required. Oversees and supervises investigations conducted by other members of the supervisory team.
• Oversees the resident complaint management program. Performs initial intake for complaints and quality concerns regarding the delivery of resident services and professional practice standards. Communicates with complainants to acknowledge receipt, clarify information, respond to questions, and provide information regarding processes and practices. Ensures complaints are responded to within the legislative requirements and closes incidents not requiring full investigation. Prepares quarterly and annual analysis, identifies trends and leads actions required to improve operational standards and practices.
• Serves as a mechanism of escalation when there are concerns regarding an investigation that requires strategic expertise. Provides coverage and serves as designate to the Manager of Resident Care and Administrator.
• Manages documentation practices, including electronic documentation for resident assessments, and reports and statistics per legislation. Oversees the resident assessment instrument minimum data system.
• Works with Quality and Risk Coordinator and corporate privacy staff to provide guidance and oversight under the Personal Health Information Protection Act (PHIPA) and Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) with regard to releasing and tracking documents.
• Identifies potential risks and possible breaches of standards and legislation to form investigation plans, scope of investigation, level of risk/severity, and other considerations.
• Documents and presents evidence, ensuring analysis and summaries are thorough and objective. Takes detailed notes that may be used for disciplinary actions and in legal proceedings.
• Determines areas of non-compliance with provincial legislation, standards, and program standards.
• Prepares investigation reports and remedial and corrective actions and recommendations, including training, discipline, and process changes. Presents to supervisor and senior management.
• Briefs supervisor on the status of investigations and consults on high risk, complex, political, and sensitive files. Identifies potential investigative barriers and recommends effective solutions.
  Completes incident reports, including reporting to the Ministry.
• Provides expertise and guidance to staff regarding interpretation and application of standards.

Additional Duties/Responsibilities

• Maintains investigation files and program records. Ensures records are accurate, current, and detailed enough to meet quality assurance standards and for Ministry reporting and compliance. Documents, tracks, and closes completed files for all levels of complaints and concerns.
• Compiles files and documentation requested by the Ministry of Long-Term Care for external investigations. Provides support to facilitate onsite inspections (e.g., booking rooms, preparing information, coordinating schedules).
• Backs up Manager, Resident Care as required.
• Performs related duties as required.

Knowledge, Skills, and Abilities

• Knowledge and skills are acquired through of a Bachelor of Science Degree in Nursing, or equivalent education in the Health Sciences disciplines, plus related experience.
• Must have current registration with the College of Nurses of Ontario as a Registered Nurse or as a Registered Nurse in the Extended Class.
• Knowledge of resident care and gerontological nursing, psychogeriatric and palliative care, long-term care, recreational and physical therapy, and community resources.
• Demonstrated skill and experience conducting formal investigations in a health care or other highly regulated industry.
• Demonstrated skill and experience in investigative, unbiased interviewing techniques, methodologies, and practices, including professional report writing and documentation.
• Demonstrated skill and experience handling complaints and concerns from the public (including de-escalation skills).
• Knowledge and understanding of long-term care services operations and standards, including Ministry documentation standards, policies, procedures, and guidelines.
• Knowledge of quality assurance methodologies.
• Knowledge of and ability to comply with policies, procedures, collective agreements, regulations, standards (e.g., documentation, equipment, patient care), related legislation (e.g., Fixing Long Term Care Act, health and safety, PHIPA, MFIPPA, disability).
• Leadership skills to provide guidance, support, and maintain trusting relationships.
• Ability to represent the Division and demonstrate professionalism and integrity when conducting investigations and interacting with the public.
• Ability to work independently, ensuring timely completion of investigative reports and recommendations.
• Communication, de-escalation, presentation, and human relations skills to explain policies, procedures, and standards to the public, paramedics, management, and other stakeholders; conduct interviews; present evidence, provide consultation, expertise and investigative reports to management; and participate as an effective team member.
• Research, analytical, problem solving, and organizational skills to collect, organize, and analyze evidence and identify trends; and recommend and implement process improvements.
• Ability to write investigation reports, recommendations, correspondence, detailed notes, and maintain records.
• Ability to read and interpret reports, records, legislation, and standards, including patient documentation and call reports, standards, communications, and policies and procedures.
• Computer skills with ability to use software such as Microsoft Office (including Excel), and electronic health records systems.
• Ability to travel within Waterloo Region.
• Must have a tuberculosis test and all required immunizations.
• Must provide an acceptable vulnerable sector police records check.
• Ability to participate in an official standby/on-call rotation to respond to legislated or time sensitive demands beyond regularly scheduled work hours.
• Ability to work flexible hours to accommodate training for different shifts. Ability to work variable shifts, including evenings, holidays and weekends, as required.
• Ability to support and demonstrate the values of Seniors’ Services and the Region.