Quality Assurance (QA) Manager

POSITION SUMMARY

The Quality Assurance (QA) Manager is responsible for ensuring that Divine Help Healthcare Services, Inc. maintains full compliance with Maryland Developmental Disabilities Administration (DDA) regulations (COMAR 10.22), licensing standards, and all applicable state and federal requirements governing services to individuals with intellectual and developmental disabilities (IDD). This role leads the agency's Quality Assurance/Quality Improvement (QA/QI) program, oversees incident management and reporting, monitors documentation and staff training compliance, and supports the agency's readiness for licensing surveys and audits.

KEY RESPONSIBILITIES

Regulatory Compliance & Licensing

Ensure ongoing compliance with COMAR 10.22 (DDA regulations), applicable waiver requirements (Community Pathways, Family Supports, Community Supports), and Maryland DDA licensing standards.

Serve as the agency's primary point of contact for DDA, the Office of Health Care Quality (OHCQ), Adult Protective Services, and other regulatory bodies during audits, surveys, and inspections.

Monitor DDA policy transmittals and regulatory updates, and revise agency policies and procedures accordingly.

Quality Assurance & Quality Improvement

Develop, implement, and maintain the agency's QA/QI plan, including internal audit schedules, record reviews, and corrective action tracking.

Audit Individual Plans (IP), Behavior Support Plans (BSP), Person-Centered Plans, progress notes, and data collection for accuracy, timeliness, and regulatory alignment.

Track and trend incident data, identify patterns, and lead root-cause analysis and corrective action planning.

Prepare and present QA reports and outcomes to executive leadership and, as required, to DDA and other licensing bodies.

Incident Management

Oversee the agency's Critical Incident Report (CIR) process, ensuring timely and accurate reporting through the required state reporting system.

Investigate incidents as needed, ensure proper documentation, and confirm that corrective actions are implemented and effective.

Coordinate with the Delegating Nurse, Program Coordinator, and direct support staff to ensure incidents are addressed per DDA and agency protocol.

Staff Training & Compliance Oversight

Monitor staff training compliance, including annual required trainings, Behavior Plan (BP) training and signature documentation, Medication Administration (MAP) certification, CPR/First Aid, and other DDA-mandated trainings.

Ensure training dates align with the implementation dates of Behavior Plans and other individualized supports, consistent with DDA and licensing/audit requirements.

Partner with the Program Coordinator and Human Resources to identify and close training gaps.

Documentation & Records Management

Ensure individual records — health, behavioral, and programmatic — are complete, accurate, current, and audit-ready at all times.

Maintain organized systems for tracking licensing documents, staff credentials, and required certifications.

Support the timely completion and submission of Statements of Deficiency (SOD) responses and Plans of Correction (POC).

Risk Management & Safety

Identify risk areas across residential and day program sites and recommend and implement mitigation strategies.

Support health and safety compliance, including medication administration audits and infection prevention practices.

Participate in the agency's Human Rights Committee, Behavior Support Committee, and other internal review committees as required.

QUALIFICATIONS

Education & Licensure

Bachelor's degree in Nursing, Human Services, Social Work, Psychology, or a related field required.

Advanced clinical licensure preferred; additional certifications (e.g., CPR/First Aid Instructor, MAP Trainer) a plus.

Experience

Minimum 3–5 years of experience in a DDA-licensed or IDD/behavioral health service setting, including at least 2 years in a quality assurance, compliance, or program oversight role.

Demonstrated knowledge of COMAR 10.22, Maryland DDA waiver programs, and Person-Centered Planning principles.

Experience preparing for and participating in state licensing surveys and audits.

Skills & Competencies

Strong understanding of incident management systems and DDA Critical Incident Report (CIR) requirements.

Excellent written and verbal communication skills, with the ability to prepare clear, professional reports for leadership and regulatory bodies.

Detail-oriented with strong analytical and organizational skills.

Proficient in Microsoft Office (Word, Excel) and electronic documentation/record systems.

Ability to maintain confidentiality and exercise sound, independent judgment.

Valid driver's license and reliable transportation for travel between program sites.

WORK ENVIRONMENT & PHYSICAL DEMANDS

Primarily office-based, with regular travel to residential and day program sites throughout the service area.

May require occasional evening or weekend availability to respond to urgent incidents or audits.