Associate Director of Health Care

Assist Director of Regulatory Affairs in overall management and operations of the Regulatory Affairs Department including: staff education, coordination and monitoring of facility survey readiness and other survey-related activities.

1. Participate in survey preparedness and readiness activities (e.g., environmental rounding, tracer activity, mock surveys, education, monitoring) in preparation for regulatory and accreditation surveys, e.g., NYC DOHMH, NYS OMH, NYS DOH Article 28, Title 18, Behavioral Health and other announced and unannounced surveys/investigations.

2. Collect, analyze and prepare data (e.g., key metrics and performance indicators, deficiencies/citations) for presentations and reports.

3. Develop standard tracking and monitoring tools and databases such as ongoing schedule of regulatory surveys (past and upcoming), survey findings, key departmental owners/stakeholders, policies and procedures, regulatory agencies and key contacts.

4. Facilitate and prepare documents for department meetings, including but not limited to scheduling, preparation of agendas, minutes, attendance, meeting materials, tracking issues and follow-up items.

5. Work with Director and clinical and administrative stakeholders to develop, maintain, and update policies and procedures

a. Maintain online library of policies and procedures

b. Facilitate/ coordinate approval of policies and procedures

6. Assist departments/programs to ensure ongoing compliance with applicable laws, rules, and regulations for ongoing survey readiness as well as for upcoming surveys.

7. Assist in preparation, instruction and review of plans of correction

8. Monitor plans of correction from external surveys as well as internal reviews

9. Continuously review regulatory/accreditation agencies websites for revisions and updates to standards, rules, and regulations

10. Conduct education on creating compliance monitoring tools, preparing plans of correction, and preparing for regulatory surveys

11. Establish standardized, ongoing monitoring and tracking process for vendor agreements.

12. Provide support to/serve as back up for the Designated Facility Research Coordinator for Metropolitan

a. Ensure that research activities comply with NYC Health + Hospitals and Metropolitan policies and procedures as well as with external regulations, e.g. human subjects? protections, conflicts of interest, Institutional Review Board (IRB)

b. Review and approve research protocols (administratively) and provide feedback to research teams to ensure required elements and forms are submitted

c. Run reports from the System for Tracking and Approving Research (STAR)

13. Provide support to/serve as back up for Office of Student Affairs as needed:

a. Assist in development and execution of clinical student agreements

b. Oversee maintenance of department databases (e.g., students, schools, programs, key contacts, fees, and rotation calendars)

c. Ensure student compliance with workforce requirements, e.g., mandated training and education (HIPAA, Annual In-Service, etc.)

14. Assist in overall operations of the Regulatory Affairs Department, including special projects and other duties as assigned.