Maribel Fernando

• POSITION SUMMARY: The Compliance and Human Resources Officer role at Texas Dermatology is a crucial position tasked with upholding the organization's compliance with healthcare laws and internal HR policies. This role is responsible for the creation, implementation, and ongoing management of a comprehensive compliance program that adheres to state, federal, and industry-specific regulations. It involves a strategic approach to risk assessment, with the objective of identifying, evaluating, and mitigating potential compliance risks. Conduct comprehensive assessments to identify potential areas of compliance vulnerability and risk; develop and implement corrective action plans for resolution of problematic issues. Develop a risk management strategy that includes detailed risk evaluation, mitigation tactics, and periodic reassessment which includes Performance & Process Improvement plans and initiatives using quantifiable and measurable metrics. Improve processes for surgical and cosmetic procedures with priority given to Mohs Micrographic surgery through direct observation of procedures to identify areas for improvement and in preparation for regulatory surveys and audits- FDA, CMS, HHSC.
• Audited more than100 patient charts of Providers for current quarter using the audit tool and the Performance Improvement Plan template created.
  • Obtained the Clinical Laboratory Improvement Amendments (CLIA) re-accreditation for the clinic’s laboratory for Mohs’ surgeries.
  • Created the process for measuring department Key Performance Indicators (KPI’s) using electronic reports and Providers’ KPI’s through quality quarterly patient chart audits.
  • Revised PTO benefits from accrual to front-loaded which were approved and implemented.
  • Performed current market analysis of employees and submitted recommendation to Practice Administrator for approval.
  • Secured better insurance coverage for employees by partnering with a reliable broker.

• POSITION SUMMARY: Established the Quality Assurance & Performance Improvement Department. Manages the Quality Assurance and Performance Improvement Department by overseeing all compliance requirements and serving as the lead person for all regulatory surveys. Supervises staff and provides the concept and framework for all projects related to internal and external Quality Assurance & Performance Improvement. Directs the development of procedures and controls to ensure organizational compliance. Maintains Continuous Quality Monitoring (CQM) and Quality Improvement (CQI) programs within and outside of the organization. Creates Statement of Work (SOW) and acts as a reviewer of all SOW’s, Request for Application (RFA), Request for Quotation (RFQ), Request for Information (RFI), Request for Proposal (RFP). Handles HIPAA and Privacy reports based on Policy & Procedure and escalate the reporting of any situation needing the intervention of the University’s Compliance Department.
• Scored 100% on five series of surveys from the audit conducted by the Health and Human Services Commission (HHSC). These are the first state audits for Be Well Texas.
  • Created the Policy & Procedure for Quality Monitoring for the organization.
  • Created specific audit tool for Quality Monitoring of the different programs for Be Well Texas.
  • Audited almost two hundred Providers to date and required Performance Improvement Plans which are monitored for proper and timely implementation of action steps.
  • Organized and launched the Quality Assurance and Performance Improvement Program.
  • Provided the concept and framework to measure Provider Capacity and spend-down through the use of Tableau reports.
  • Regularly reviewed SOW’s, RFA’s, RFP’s, RFI’s, Monthly, Quarterly, Annual, Close-Out Reports for submission to HHSC.
  • Created a platform to collect Government Performance and Results Act (GPRA) questionnaires
  for Providers not using the Clinical Management and Behavioral Services (CMBHS) state website.
  • Reviews and approves all monthly, quarterly, and end-of year reports submitted to the state through Global scape.
  • Delivered at least sixty-five presentations to Providers, HHSC Project Managers and leadership.
  • Presented "Survey Readiness"- Sustainability ECHO, 04/23/2023.
  

POSITION SUMMARY: Manages the Quality Assurance and Improvement Department which oversees quality standard and compliance requirements of two companies, DSSW (DBMD, CLASS, Star Kids) and LifeSpan (Home Health, PAS). Creates process improvement initiatives in compliance with regulations to simplify requirements and encourage proper and timely completion to meet deadlines. Provides assistance with all contract monitoring and regulatory surveys of all of the companies’ 33 locations and reviews or creates Corrective Action Plans (CAPs) or Plan of Corrections (POCs) for survey deficiencies.

• Established and oversaw company-wide Quality Management System (QMS), maintaining compliance with HHSC, CMS, CHAP and enhancing internal outcomes.
• At least 30 process improvement project initiatives have been implemented which include flow charts with deadlines for submissions, fillable forms, and detailed instructions. One of those are employee and client/patient satisfaction surveys with QR Codes (Spanish and English) with responses analyzed for trends being used to create process improvement plans.
  • Created annual reports for both companies and present them to the CEO, COO, and administrators of offices. This includes a graphical presentation of Quality Indicators with trends and comparative analyses.
  • Creates, modifies, updates and amends policies based on existing regulations and in consonance with internal operations. Uploads updated policies to company intranet after approval by the Policy Committee.
  • Developed the companies QAPI Program which includes the QAPI and Performance Improvement Plan Manuals. CHAP surveyor complimented the program as the best she has seen.

POSITION SUMMARY: Promotes commitment to corporate and subsidiary standards, policies, and procedures. Assists in the monitoring of clinical processes and the establishment of procedures to reduce identified problem areas as well as advise or recommend solutions for improvement, using knowledge of theory, principles, or technology. Assists all Texas agencies in developing and maintaining standardized procedures that provide for an independent, impartial, and objective system of surveys, clinical audits, and reviews. Identify strengths and weaknesses and recommending procedures, data collection tools, and reporting and follow-up processes for surveys and reviews; determine the best metrics for evaluating success; and assist agencies in developing

quality plans to facilitate change and compliance with company and accreditation standards as well as state and federal regulations. Ensure quality standards are met by instructing and directing staff in developing and using QI data, collection procedures, analysis methods, and systems. Identify corporate resources and support for agency staff; develop clinical programs and training material; instruct agency personnel on compliance standards and best practices in the generation of appropriate, accurate, and thorough documentation of patient care; and create training programs, materials, and implementation schedule to meet agency goals. Develop and implement clinical and business management systems to promote adherence to applicable legal requirements, standards, policies, and procedures as well as interdisciplinary approach to holistic care. Monitor Outcome- Based Quality Monitoring (OBQM) and implement strategies for performance improvement; recommend new or improved organizational systems with a quality improvement approach.

• Member of the Merger and Acquisition Team in conducting “Due Diligence” for companies being acquired. Report on the audit is submitted for consideration on the M&A decision of company stakeholders.
  • On-site audit of Texas locations for quality review and compliance with state regulations and report findings to top management via scheduled conference calls.
  • Created flow charts, instructional materials with screen shots, templates, and other reference materials for process improvement.
  • Reviews QAPI and EPPI reports of locations before finalizing and filing them in their respective compliance binders.
  • Approximately 398 ANE client allegation reports were reviewed in one year before submitted to HHSC. This resulted in quality of reports being submitted which resulted in HHSC’s decision of “unsubstantiated complaints”.
  • Participated in interviews involving self-reported complaints of Providers.
  • Regularly audited EVV (Electronic Visit Verification) compliance of all TX locations to determine that accurate billing is submitted to HHSC. A significant amount was recommended for negative billing before payment, which helps avoid penalties.

POSITION SUMMARY: Responsible for overall planning, development, and direction of Personal Assistance Service Program, including budget management; ensuring program services match and meet both agency and program objectives; and supervision and performance evaluation of staff. Oversee compliance, billing/ payroll and human resource including client satisfaction surveys for process improvement as part of Quality Assurance Performance Improvement of company.

• Modified Client Satisfaction Survey form by simplifying responses to encourage participation and easily track trends and data that can be used to improve system and process.
  • Scored 100% on the recent HHSC contract audit which the company previously lost prior to assumption as Director.
  • Increased census from 97 to 142 clients.
  • Restructured in-service training and orientation and trained 130 attendants for the Electronic Verification Visit (EVV).

POSITION SUMMARY: Responsible for determining strategies and executing program help the 45 CSS offices improve profitability and customer satisfaction through the right mix of Quality Caregivers, Care Solutions, and Active Involvement. Ensure that all offices are operating according to prescribed state regulations and quality set by the office by ensuring that required policies are in place. Committee chairperson for the company’s operational process improvement and spearheaded projects geared towards client (employees, clients, referral sources) satisfaction.

• Enhanced clients’ experience by continuously researching and implementing bests solutions for
  The client’s specific needs, medical situations ,and interests, following company policy and
  procedures and state regulations.
  • Successfully managed client concerns resulting in good client relations and repeat referrals.
  • Initiated and accomplished quality projects such as the revision of the operations manual and
  related materials–forms, hand-outs, brochures.
  • Instrumental in obtaining license for newly opened offices and successful completion of state
  surveys of existing offices.
  • Delivered quality training as subject matter expert such as but not limited to QAPI to Agency
  directors and Care Managers during orientations, quarterly and annual conferences.

POSITION SUMMARY: Directed the Assisted Living program, focusing on the delivery of quality and efficacious care to each resident. Ensured that Senior Lifestyle and state requirements for resident care were met. Directed staff, ensured regulatory compliance, and was responsible for the management of the Assisted Living budget.

• Established policies and procedures in Assisted Living in conformity with state regulations upon assumption to duty.

•Helped, improved, and maintained census by successfully “closing the back door”.

• Properly managed more than five state surveys resulting in no deficiency citations from any survey.
• Best Improved Level of Care and Medication Management for AL Wizard – Dallas Regional Conference - January 2008.
• Established good linkage with home health and hospice agencies, rehabilitation centers, hospitals, and other professional groups.