Beverly K. Johnson

• Data entry of Risk Management reports (infections, wounds, falls, incident reports, complaints)
• Prepared and presented Quarterly QAPI reports to staff
• Involved in training as a "superuser" for new Hospice software
• Prepared and provided education for staff (worked in tandem with Director Health Care Services)
• Part of Emergency Preparedness planning, updating, education
• Received Hospice Information Set (HIS) forms; processed, submitted to CMS
• Entered patient information into HealthCare First for submission so post-care evaluation surveys could be sent to patient survivors as part of STAR program
• Provided staff education on HCF and HCAHP survey, STAR program
• Participated in tri-annual survey 06/22; no deficiencies cited with this survey
• Orientation of staff in all Hospice positions
• Authored guidelines as needed for local hospice staff.
• Participated in workshops and in-service meetings to enhance personal growth and professional development
• Used job-related software to draft and finalize written correspondence and documentation
• Prepared agendas and took notes at meetings to archive proceedings
• Evaluated operational practices and identified improvement opportunities to develop revisions for systems and procedures

• Greeted, registered each person waiting by name, description, and ID of surgical patient. Managed, on average day, more than 50 people.
• Kept track of where families were during their wait; provided messages to them as necessary
• Managed seating chart by which physicians could locate family members at end of surgery
• Accompanied families to critical care units as their loved one was transferred to unit
• Provided emotional support to families (sitting with them, providing private waiting room, etc.) with crisis patient
• Ensured atmosphere of waiting room was warm, friendly, quiet, and safe
• Communicated with surgery, pre-op, and post-op recovery
• Provided communication from physicians to patient family
• During COVID, infection control measures were enforced and followed by all persons waiting; cleaned all waiting areas daily.

• Provide consultation regarding home care regulations and agency practices
• On-line clinical record review (log into agency EMR)
• Provide staff education on documentation
• Provide staff education on documentation
• Preparation for site visit for home health or hospice agency seeking accreditation
• Conduct regulatory focused site visit
• Provide written report to agency.

unemployed

• Preparation for site visit for home health or hospice agency seeking accreditation
• Coordinated planning site visits with agency
• Conducted regulatory focused site visit
• Provided written reports to agency and home office.

• Preparation for site visit
• Conduct all phases of site visit
• Provide consultation and education to agency staff during site visit
• Identify out-of-compliance regulations
• Review site visit result with agency
• Prepare and submit report of findings from site visit
• Maintain contact with Director of Accreditation during site visit.

• Unemployed due to the needs of aging parents.

• Developed Home Health Agency in preparation for state licensure and national accreditation
• Managed agency personnel, direct care, and administration
• Managed computerized documentation program; educate staff
• Developed, planned, educated, and chaired required Professional Advisory and Ethics committee
• Resource to all staff regarding regulations and procedures
• Developed and presented Home Health education
• Provided, managed and coordinated patient care
• On-call 24/7/365
• Developed survey book, education of staff, and active participation in survey process
• Developed successful plans of correction for citations from survey
• Developed and implemented clinical spread sheets to track OBQI/QA and other information
• Developed and managed QA program
• Created documentation forms as needed; update existing forms
• Reviewed, revised, authored additional policies, implemented, educatee and monitored compliance of Policies and Procedures
• Investigated complaints, issues presented by staff, patients; tracked and resolved complaints made known to agency
• Compliance and Privacy officer for local office
• Responsible for Workers Compensation program
• Resource to other Vizion One Home Health offices at their sites and electronically
• Developed successful plans of correction for survey citations in other home health locations.

• Developed Home Health Agency to accreditation by CHAP (Community Health Accreditation Program) and certification by Medicare/Medicaid
• Managed agency personnel, direct care, and administration
• Managed computerized documentation program; educate staff
• Developed, planned, educated, and chaired required Professional Advisory and Ethics committee
• Resource to all staff regarding regulations and procedures
• Developed and presented Home Health education
• Managed and coordinated patient care
• On-call 24/7/365
• Provided direct patient care prior to hiring staff and currently as needed
• Notary Public for staff and patients
• Developed survey book, education of staff, and active participation in CHAP survey process
• Developed successful plans of correction for citations from CHAP surveys
• Developed and implemented clinical spread sheets to track OBQI/QA and other information
• Developed and managed QA program
• Createed documentation forms as needed; update existing forms
• Reviewed, revised, authored additional policies, implemented, educated and monitored compliance of Policies and Procedures
• Investigated complaints, issues presented by staff, patients; track and resolve complaints made known to the agency
• Compliance and Privacy officer for local office
• Responsible for Workers Compensation program
• Resource to other Vizion One Home Health offices at their sites and electronically
• Developed successful plans of correction for survey citations in other home health locations
• Involved in development of additional home health office
• Consultant
• For Indiana office:
• Reviewed, revised, authored additional policies and procedures for Indiana office to ensure compliance with state regulations
• Created survey book in preparation for survey
• Reviewed clinical and personnel records prior to survey, identifying deficiencies
• Developed plans of care for citations from 2 Indiana state surveys
• Provided education for administrative personnel electronically and per phone (on-going)
• For other offices:
• Provide education for administrative personnel electronically and per phone (on-going)
• Resource for documents, processes, etc.
• Worked with staff to develop and implement best practices to improve patient outcomes.

• Developed Hospice with certification by CHAP (Community Health Accreditation Program) and Medicare
• Managed personnel of agency, direct care and administrative
• Resource to all staff with regard to regulations of all types
• Developed and presented Hospice education for staff
• Director of Health Care Services in coordinating care of patients, running Interdisciplinary Group Meetings
• Instrumental in the development of Plans of Correction for CHAP citations from initial survey
• Developed and implemented clinical spread sheets to track patient certification periods, Length of Stay, Census, etc
• Developed and implemented multi-tabbed QA spread sheets for tracking QA
• Created forms as needed
• Authored, educated, implemented, and monitored compliance with Policies and Procedures for the agency
• Hired personnel as needed to ensure qualified and sufficient numbers of staff were available to provide care
• Provided guidance in development and oversight of Bereavement and Volunteer programs
• Investigated as appropriate all reports of possible or known abuse, neglect, exploitation of patients in addition to receipt, investigation, tracking, and resolution of complaints made known to the agency
• Responsible for Workers Compensation activities.

• Program)
• Functions:
• Assessed, coordinated, monitored and provided health care services and treatment for HOPE participants, and coordinated quality improvement development, support, data collection, and analysis
• Developed and managed QAPI program as developed with Medical Director and the QAPI committee
• This program was instrumental in a very successful CMS survey
• Developed annual work plan in collaboration with the QAPI committee and administration
• Chaired QAPI committee, served as member to all QAPI sub-committees, Action Teams, and work groups
• Managed and retained all committee documents in an organized manner to ensure ongoing program compliance and reports
• Oversight of collection, monitoring and reporting of all QAPI, service delivery, and utilization data, maintaining systems to show data trends
• Analyzed, summarized, and validated program data/outcome data for monitoring and utilization review requirements and external data reporting requirements
• Assisted in monitoring and oversight of contract providers for compliance with regulatory and QAPI standards of care
• Chaired Compliance Committee; managed all related tasks and assignments; directed and/or facilitated Fraud, Waste and abuse prevention, monitoring, reporting, and education
• Coordinated and managed annual review of all program Policies and Procedures, working with team members to amend and/or revise policies as appropriate
• Facilitated scheduled and random audits of program procedures and compliance
• Analyzed, developed appropriate action on and reported audit findings to the Compliance and QAPI committees
• Remained apprised of compliance related updates related to program requirements, QAPI and QAPI reporting requirements, and Medicare Part D and reporting requirements.

• Functions:
• Ensured delivery of patient care is done with respect of and compliance with regulations by well-trained, competent persons
• Provided on-going regulation education for staff
• Ensured administrative functions occur with respect to and compliance with regulations
• Participated in Quality Assurance and Performance Integrity functions of Hospice Care of Kansas/Hospice Care of the Midwest, and Voyager Hospice Care Inc
• Resource to all staff with regard to regulations of all types that impact the functioning of Hospice Care of Kansas/Hospice Care of the Midwest
• Authored, educated, implemented, and monitored compliance with Policies and Procedures for the agency
• Investigated and reported to authorities as appropriate all reports of possible or known abuse, neglect, exploitation of patients
• Stayed informed of all reports to Adult Protective Services for those patients living in a private residence
• Provided education to staff regarding compliance issues (Compliance program, Regulations, In-services, Documentation)
• Supervised Program Integrity Coordinator, Medical Records Manager and Medical Records File clerk
• Chaired Ethics Committee; lead development and implementation of this Committee during the spring 2008
• Participated in surveys of all types by being the contact person for surveyors and being a “buffer” between staff and compliance personnel
• Participated in the development of Plan of Correction in the event of a deficient finding by a survey team
• Lead development of Professional Advisory Committee for each branch office and chair meetings
• Provided detailed monthly Program Integrity report of compliance activities to Executive Leadership Team; this report included quarterly information also
• Produced annual Program Integrity report for presentation at Professional Advisory Committee
• Attended Executive Leadership Team, Director of Patient Services and Patient Care Managers monthly meetings
• HIPAA Privacy Officer and carry out all perform all required functions thereof.

• Responsible for Workers Compensation activities for most of the 3 years of employment
• Functioned as a member of the Special Projects Committee, a group designed to plan special projects of recognition for employees
• Provided oversight for and was part of the Forms Committee
• Reviewed all correspondence to be sent out of the office to the public to ensure accurate information is presented in a professional manner
• Worked with other administrative personnel in CHAPs certification process
• Contact person for questions of families when Non-Medicare Coverage notice is given prior to discharge of a patient; Participated in ADR process: responsible for review, preparation and timely sending of all clinical records requested for ADR
• Responsible for review, preparation and timely sending of all clinical records requested for CERT
• Co-managed extended length of stay auditing
• Provided leadership for staff in reviewing patient eligibility, use of LCD's (local coverage determination provided by CAHABA, and auditing in the process
• As a result of interventions, nursing staff developed in-depth knowledge of eligibility criteria; each RN Case Manager reviewed assigned patients prior to my visit to the branch office so my primary function was review and oversight.

• Reorganized Safety Committee into Risk Management Team which evaluated minimally on a monthly basis risk management/safety concern of the facility
• Chaired monthly meeting; conducted “impromptu” meetings as needed to ensure Risk Management concerns were addressed
• As part of the SHARP certification process, writing a Safety Program was required
• Upon completion of the writing of the program, that work received high praise from OSHA Consultants and the plan remains in effect at the facility.

• Developed, educated staff, implemented and monitored privacy Policies and Procedures to ensure HIPAA regulations were met
• Carried out functions of privacy officer as required by HIPAA
• Provided education to staff regarding privacy practices.

• Planned, developed, presented, revised education programs for all aspects of long-term care, including survey processes.

• Developed, educated, implemented and monitored policies and processes to ensure all employees were knowledgeable of and functioned according to Standards of Practice; Standards of Conduct; Federal and State Regulations
• This included Corporate Compliance and Quality Assurance programs
• Contact person for all survey activities
• Lead the process of achieving SHARP Certification for the facility; an intense sixteen (16) month project which put in place OSHA requirements showing that management had a true commitment for safety of employees
• This activity included being always present when the OSHA consultant did all (numerous) walk-through observations, writing
• Participated in OSHA investigations of complaints against facility
• Responsible for the oversight of Workers Compensation activities (evaluation of injury, secured medical treatment as necessary, worked with HR to ensure employee rights were respected, statistic tracking/reporting, education of staff regarding safety matters) for at least seven (7) of the years employed at the facility
• Received annual Asbestos education and was active in process of removal of asbestos from the facility; responsible for notification to contractors with a need to know the location of the asbestos.