Assistant Director Risk Management and Compliance

Essential Responsibilities

1. Incident Management

• Assist with the review and processing of incident reports involving residents, employees, visitors, and facility operations.
• Monitor incident reports for completeness, accuracy, timeliness, and appropriate follow-up.
• Assist in identifying trends, patterns, and recurring concerns.
• Ensure incidents are routed to the appropriate leadership personnel for review.
• Assist with determining whether additional investigation, notification, or corrective action is necessary.
• Maintain accurate and organized incident documentation.
• Follow established procedures for serious, critical, unusual, or reportable incidents.
• Assist with tracking required follow-up actions to completion.

1. Incident Investigation Under the direction of the Risk Manager:

• Assist with conducting fact-finding investigations.
• Review documentation, medical records, video when authorized, photographs, statements, and other relevant information.
• Interview employees and other individuals as appropriate and within organizational policy.
• Maintain objectivity and confidentiality throughout the investigation process.
• Prepare investigation summaries for review by the Risk Manager or appropriate leadership.
• Identify contributing factors and potential system issues.
• Assist in developing recommendations to prevent recurrence.

1. Risk Identification and Assessment

• Assist in identifying actual and potential risks throughout the facility.
• Participate in routine environmental and safety rounds.
• Identify hazards related to resident care, staffing, equipment, environment, documentation, communication, and facility operations.
• Assist with risk assessments and mitigation plans.
• Report identified concerns promptly to the appropriate leader.
• Monitor corrective actions and follow-up activities.

1. Quality and Performance Improvement

• Assist with collecting and analyzing risk and incident data.
• Track trends involving injuries, aggression, restraints, elopement attempts, medication concerns, allegations, property damage, staff injuries, and other significant events.
• Assist with developing reports, dashboards, and presentations for leadership.
• Participate in Quality Improvement activities.
• Help identify opportunities for process improvement.
• Assist with monitoring corrective action plans.

1. Regulatory and Accreditation Support The Assistant Director will gain working knowledge of applicable requirements, including those associated with:

• Virginia Department of Behavioral Health and Developmental Services (DBHDS)
• Virginia Department of Education, when applicable
• Virginia Human Rights Regulations
• Joint Commission standards
• VASEIF requirements, when applicable
• OSHA requirements
• HIPAA and confidentiality requirements
• Applicable federal and Virginia laws and regulations
• Organizational policies and procedures Responsibilities include:
• Assisting with regulatory and accreditation audits.
• Preparing requested documentation.
• Tracking compliance-related findings.
• Assisting with corrective action plans.
• Monitoring completion of required actions.
• Maintaining organized compliance records.

1. Safety and Environmental Risk

• Participate in scheduled safety rounds and environmental assessments.
• Identify potential hazards and report them appropriately.
• Assist with monitoring emergency preparedness activities.
• Assist with reviewing safety concerns involving residents, staff, visitors, equipment, and the physical environment.
• Participate in emergency drills and post-drill reviews.
• Assist with identifying opportunities to improve facility safety.

1. Risk Management Meetings and Debriefings

• Attend Risk Management meetings and incident debriefings.
• Prepare materials and documentation for meetings.
• Assist with identifying trends and recurring issues.
• Participate in post-incident reviews.
• Assist with identifying lessons learned and system improvements.
• Maintain meeting documentation and follow-up items.

1. Documentation and Records

• Maintain accurate, organized, and confidential Risk Management records.
• Assist with maintaining incident logs, investigation files, audit documentation, corrective action plans, and risk assessments.
• Ensure documentation is completed according to established timelines.
• Protect confidential and sensitive information.
• Follow HIPAA, privacy, security, and organizational requirements. 9.

Education

and Training

• Participate in Risk Management training and professional development.
• Assist with identifying training needs based on incident trends.
• Support development of staff education related to risk prevention.
• Participate in staff education regarding incident reporting, safety, documentation, and regulatory expectations.
• Develop competency in investigation and root-cause analysis techniques.

1. Communication and Collaboration

• Develop effective working relationships with employees and leaders throughout the organization.
• Communicate risk concerns professionally and objectively.
• Work collaboratively with Human Resources, Clinical Services, Nursing, Residential Services, Education, Medical Services, Quality, Compliance, and Executive Leadership.
• Escalate significant concerns promptly.
• Maintain professionalism when discussing sensitive or potentially difficult issues. Development Responsibilities The Assistant Director will be expected to progressively develop competency in the following areas: Phase I – Orientation and Observation
• Learn the organization's Risk Management program.
• Learn incident reporting requirements.
• Review organizational policies and procedures.
• Learn regulatory and accreditation expectations.
• Shadow the Risk Manager during incident reviews, investigations, audits, and safety rounds.
• Learn confidentiality and documentation standards. Phase II – Guided Practice
• Assist with incident reviews.
• Participate in investigations under supervision.
• Complete assigned safety rounds.
• Assist with incident trend reports.
• Participate in debriefings.
• Assist with regulatory preparation and audits.
• Complete assigned risk assessments. Phase III – Increased Responsibility
• Independently complete assigned Risk Management tasks.
• Conduct routine reviews with limited supervision.
• Identify trends and recommend potential interventions.
• Assist leadership with corrective action plans.
• Present findings to the Risk Manager.
• Demonstrate appropriate judgment regarding escalation of risk concerns. Phase IV – Risk Management Readiness The Assistant Director should demonstrate competency in:
• Incident investigation
• Root-cause analysis
• Risk assessment
• Regulatory compliance
• Safety management
• Incident trend analysis
• Corrective action planning
• Documentation
• Confidentiality
• Professional communication
• Critical thinking
• Leadership collaboration Successful completion of the trainee program may result in consideration for advancement to a Risk Manager position when an appropriate opportunity becomes available.
• Exempt (salaried - not eligible for overtime) JOB REQUIREMENTS Minimum Education Bachelor’s degree in healthcare administration, behavioral health, criminal justice, business administration, risk management, or a related field required Equivalent relevant experience may be considered. Additional training or certification in risk management, healthcare compliance, investigations, or quality improvement is desirable Minimum Work Experience At least two years of experience in behavioral health, healthcare, residential treatment, quality assurance, regulatory compliance, incident management, investigations, or a related field Experience with incident reporting, documentation review, auditing, or corrective action tracking is highly desirable. Experience in a licensed residential treatment setting is preferred. Required Skills, Licenses / Certifications Cardiopulmonary resuscitation (CPR) First Aide Behavioral Management program within 14 days of hire Valid Driver's License in good standing General Requirements Must be at least 19 years of age per Commonwealth of Virginia Interdepartmental Regulation of Children’s Residential Facilities.

Required Skills

Knowledge and Abilities Must have patience, tact, and a cheerful disposition and enthusiasm. Ability to effectively present information to groups. Communicate in English effectively and document information accurately. Communicate effectively with all disciplines involved in the care of the resident. Ability to work well with others in a team setting and work well with a moderate level of direct supervision.

Proficient with Windows, Outlook, internet research, MS Office including Word, Excel and PowerPoint.