Who are we? Morningstar Family and Children’s Services Inc. was founded in 1996 with a desire to connect Georgia’s children with brighter days. Since then, we have grown into a multi-faceted organization that achieves our mission of providing home and healing for children through our residential care program and community counseling clinics. Our home base is located in Brunswick, GA. We are seeking a highly organized and detail-oriented Quality Assurance Coordinator to join our team.
JOB DESCRIPTION
Position Title
Quality Assurance Coordinator – RCCL & CARF Compliance
Reports To
COO
Employment Status
Full-Time
Position Summary
The Quality Assurance Coordinator is responsible for coordinating, monitoring, and supporting the agency's quality assurance, regulatory compliance, risk management, and continuous quality improvement activities within a residential foster care environment.
The position ensures that agency programs, services, documentation, personnel practices, residential operations, and client care activities are consistently aligned with applicable RCCL licensing requirements, CARF accreditation standards, agency policies and procedures, contractual requirements, and applicable federal, state, and local regulations.
The Quality Assurance Coordinator serves as a key resource for identifying compliance risks, monitoring corrective actions, conducting internal audits, preparing for licensing and accreditation reviews, maintaining quality assurance records, and promoting a culture of continuous improvement throughout the organization.
CARF's quality framework emphasizes obtaining stakeholder input, implementing plans, reviewing measurable results, and using those results to effect improvement. The Quality Assurance Coordinator plays a central role in maintaining this continuous improvement cycle.
Essential Duties and Responsibilities
1. Regulatory and Accreditation Compliance
- Monitor agency compliance with applicable RCCL licensing requirements and CARF accreditation standards.
- Maintain current knowledge of changes to applicable licensing regulations, CARF standards, contractual requirements, and agency policies.
- Conduct periodic reviews of agency operations to identify areas of compliance and potential deficiencies.
- Maintain a regulatory and accreditation compliance calendar.
- Track required inspections, certifications, licenses, background screenings, training requirements, renewals, and other regulatory deadlines.
- Assist leadership in interpreting and implementing new or revised regulatory and accreditation requirements.
- Maintain documentation demonstrating compliance with applicable standards.
- Coordinate preparation for RCCL inspections, CARF surveys, audits, and other external reviews.
- Maintain organized evidence files for licensing and accreditation requirements.
2. Internal Quality Audits
- Develop and maintain an annual Quality Assurance Audit Plan.
- Conduct scheduled and unscheduled audits of residential programs, client records, personnel files, training records, incident documentation, medication records, safety documentation, and other applicable records.
- Review case files for completeness, accuracy, timeliness, and compliance.
- Review documentation related to admissions, assessments, treatment/service plans, progress notes, discharge planning, placement documentation, and follow-up services.
- Conduct residential site reviews to evaluate compliance with health, safety, environmental, staffing, supervision, documentation, and program requirements.
- Identify trends, deficiencies, and opportunities for improvement.
- Document audit findings and communicate results to appropriate leadership.
3. Corrective Action and Performance Improvement
- Develop and maintain Corrective Action Plans (CAPs) for identified deficiencies.
- Assign corrective actions to responsible departments or individuals in collaboration with leadership.
- Establish reasonable completion dates and monitor progress toward resolution.
- Verify that corrective actions have been effectively implemented.
- Conduct follow-up audits to determine whether deficiencies have been corrected and sustained.
- Escalate overdue or high-risk corrective actions to appropriate leadership.
- Maintain a centralized corrective action tracking system.
4. Incident and Risk Management
- Monitor and review critical incidents, unusual incidents, accidents, injuries, allegations of abuse/neglect, AWOL/runaway events, medication errors, restraints, property damage, grievances, complaints, and other reportable events as applicable.
- Ensure required incident reports are completed accurately and timely.
- Verify that required notifications and regulatory reports have been completed.
- Identify patterns and trends involving incidents, safety concerns, client complaints, staff performance, or residential operations.
- Participate in incident review and root-cause analysis when appropriate.
- Make recommendations designed to reduce recurrence and improve safety.
- Maintain documentation of incident reviews and resulting corrective actions.
5. Quality Improvement Program
- Assist in developing and maintaining the agency's Performance Improvement/Quality Improvement Program.
- Collect, analyze, and report quality indicators and performance data.
- Develop and monitor key performance indicators (KPIs).
- Track outcomes related to client safety, permanency, placement stability, service effectiveness, satisfaction, incidents, grievances, staff turnover, training, and other agency priorities.
- Prepare periodic Quality Assurance reports for leadership and governing bodies.
- Identify trends requiring management attention.
- Assist departments in developing measurable improvement objectives.
- Participate in Quality Assurance/Performance Improvement committee meetings.
6. Client Records and Documentation
- Conduct routine audits of client records to ensure compliance with regulatory, accreditation, contractual, and agency requirements.
- Review records for required signatures, dates, assessments, service plans, progress notes, medication documentation, incident reports, consents, releases, and discharge documentation.
- Monitor documentation timeliness and completeness.
- Identify recurring documentation deficiencies and provide feedback and training recommendations.
- Maintain confidentiality of all client information in accordance with applicable privacy laws and agency policies.
7. Foster Parent and Residential Program Compliance
- Assist with monitoring compliance of foster homes, group homes, residential facilities, and other placement settings.
- Audit foster parent/residential staff files for required credentials, background checks, clearances, training, certifications, evaluations, and documentation.
- Monitor required home inspections and safety documentation.
- Review foster parent and staff training compliance.
- Assist with monitoring supervision requirements and staffing documentation.
- Identify compliance concerns and communicate findings to the appropriate program leadership.
- Participate in corrective action and follow-up activities related to residential and foster care operations.
8. Staff Training and Technical Assistance
- Provide training and technical assistance regarding quality assurance, documentation, regulatory compliance, incident reporting, and CARF/RCCL expectations.
- Develop or assist with compliance-related training materials.
- Identify recurring deficiencies that may indicate a training need.
- Work with supervisors and managers to address staff knowledge and performance gaps.
- Assist with new employee orientation related to compliance and quality requirements.
9. Complaints, Grievances, and Stakeholder Feedback
- Monitor client, family, foster parent, employee, and stakeholder complaints and grievances.
- Ensure complaints are documented, investigated, resolved, and maintained according to agency policy and applicable requirements.
- Track complaint trends and identify systemic issues.
- Assist with client and stakeholder satisfaction surveys.
- Analyze survey results and make recommendations for improvement.
- Promote meaningful involvement of clients, families, foster parents, employees, and other stakeholders in quality improvement activities.
10. CARF Survey Preparation
- Maintain ongoing readiness for CARF accreditation surveys rather than relying solely on preparation immediately before a survey.
- Maintain a CARF standards crosswalk identifying applicable standards, responsible departments, required evidence, and compliance status.
- Coordinate internal mock surveys and tracer activities.
- Review policies, procedures, records, meeting minutes, quality data, training records, and other documentation for survey readiness.
- Assist leadership and staff in understanding CARF expectations.
- Organize survey documentation and evidence.
- Participate in survey preparation meetings and activities.
- Track recommendations or findings resulting from CARF surveys and monitor corrective action.
CARF describes its accreditation process as a comprehensive review focused on quality, safety, effectiveness, accountability, person-centered services, and ongoing performance improvement.
11. RCCL Licensing Readiness
- Maintain ongoing readiness for RCCL inspections and licensing reviews.
- Monitor compliance with applicable residential child-care licensing requirements.
- Maintain inspection and compliance documentation.
- Conduct periodic residential program compliance reviews.
- Track licensing deficiencies and corrective actions.
- Assist management with preparation for announced and unannounced inspections.
- Monitor required postings, records, emergency plans, safety documentation, staff qualifications, training, and residential standards.
- Immediately communicate significant compliance or safety concerns to appropriate leadership.
12. Reporting and Documentation
Prepare and maintain:
- Monthly and quarterly Quality Assurance reports.
- Internal audit reports.
- Corrective Action Plans.
- Quality Improvement Plans.
- Incident trend reports.
- Complaint and grievance reports.
- Client satisfaction reports.
- Staff training compliance reports.
- Licensing compliance reports.
- CARF readiness reports.
- Performance dashboards and KPI reports.
- Meeting minutes and supporting documentation.
- Regulatory and accreditation evidence files.
Required Qualifications
Education
- Bachelor's degree in social work, psychology, human services, healthcare administration, public administration, business administration, quality management, or a related field preferred.
- Equivalent education and relevant experience may be considered based on agency requirements.
Experience
- Minimum of 2–3 years of experience in quality assurance, compliance, child welfare, behavioral health, residential services, foster care, social services, healthcare, or a related field.
- Experience conducting audits, reviewing records, monitoring compliance, or developing corrective action plans preferred.
- Experience with residential child-care licensing requirements strongly preferred.
- Experience with CARF accreditation or another healthcare/human-services accreditation organization preferred.
Knowledge
The successful candidate should demonstrate knowledge of:
- Residential foster care operations.
- Child welfare practices.
- Quality assurance and continuous quality improvement.
- Regulatory compliance.
- Incident management.
- Risk management.
- Documentation standards.
- Corrective action processes.
- Performance measurement.
- Confidentiality and privacy requirements.
- Trauma-informed care principles.
- Client rights.
- Health and safety requirements.
- Accreditation and licensing processes.
Knowledge of CARF's ASPIRE to Excellence® framework is strongly preferred. CARF identifies performance measurement and management and performance improvement as core components of its quality framework.
Core Competencies
The Quality Assurance Coordinator must demonstrate:
- Attention to Detail: Ability to identify documentation and compliance deficiencies that may otherwise be overlooked.
- Analytical Thinking: Ability to identify trends and determine the underlying causes of problems.
- Organization: Ability to manage multiple audits, deadlines, reports, and corrective actions.
- Communication: Ability to communicate compliance expectations clearly to staff at all levels.
- Professional Judgment: Ability to recognize and appropriately escalate safety and compliance concerns.
- Confidentiality: Ability to protect sensitive client, employee, and agency information.
- Problem Solving: Ability to develop practical solutions to compliance and operational issues.
- Accountability: Ability to monitor corrective actions through completion.
- Collaboration: Ability to work effectively with clinical, residential, foster care, human resources, administrative, and executive staff.
- Continuous Improvement Mindset: Ability to identify opportunities to improve systems rather than simply identifying individual errors.
Key Performance Indicators
Performance may be evaluated using measurable indicators such as:
- Percentage of scheduled audits completed on time.
- Percentage of corrective actions completed by established deadlines.
- Reduction in repeat compliance deficiencies.
- Client record compliance rate.
- Personnel file compliance rate.
- Training compliance rate.
- Timeliness and completeness of incident reporting.
- Timeliness of regulatory reporting.
- Reduction in repeat incidents.
- Complaint resolution timeliness.
- Client/family/foster parent satisfaction results.
- Licensing inspection outcomes.
- CARF survey readiness.
- Completion of quality improvement initiatives.
- Timeliness and accuracy of QA reports.
Physical and Work Requirements
- Ability to work in an office, residential, and community-based environment.
- Ability to travel between agency locations, residential programs, and foster homes as required.
- Ability to review electronic and paper records for extended periods.
- Ability to attend meetings and conduct interviews with staff, clients, foster parents, and other stakeholders.
May require occasional evening, weekend, or after-hours work in response to significant incidents, inspections, audits, or a
Job Type: Full-time
Pay: From $25.00 per hour
Expected hours: 40.0 per week
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Shift availability:
Work Location: In person
