Quality Assurance Nurse

Position Summary

The Quality Assurance Registered Nurse (Hospice), reporting directly to the Executive Director, is responsible for overseeing, monitoring, and improving the quality, safety, and regulatory compliance of hospice clinical services. This role ensures compliance with all federal, state, and accreditation standards while supporting continuous improvement across the hospice program. The Quality Assurance RN works collaboratively with clinical leadership, interdisciplinary team members, and operational staff to support high-quality, patient-centered end-of-life care, accurate documentation, and timely submission of required quality reporting measures, including HOPE (Hospice Outcomes & Patient Evaluation) data.

The following duties are normal for this position. This list is not to be construed as exclusive or all inclusive. Other duties may be required and assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Oversees and supports the hospice Quality Assessment and Performance Improvement(QAPI) program in accordance with CMS requirements.
• Conducts routine and targeted clinical record audits to ensure documentation accuracy,completeness, timeliness, and compliance with CMS Conditions of Participation, agencypolicies, and accepted hospice standards of practice.
• Identifies trends, risks, and opportunities for improvement related to clinical quality, patient safety, and regulatory compliance.
• Develops, implements, and monitors Performance Improvement Projects (PIPs) incollaboration with hospice leadership to address identified quality, safety, and complianceopportunities.
• Participates in data collection, analysis, monitoring, and reporting for hospice quality initiatives and regulatory requirements.
• Oversees hospice compliance with HOPE (Hospice Outcomes & Patient Evaluation) reporting requirements, including timely completion of assessments, monitoringsubmission deadlines, and ensuring data integrity.
• Educates and supports clinical staff on HOPE documentation standards, quality reporting expectations, and regulatory updates.
• Monitors hospice quality metrics, including pain and symptom management, care planning and coordination, and patient and caregiver experience.
• Reviews open and closed hospice charts to ensure documentation supports terminalprognosis and eligibility, level of care determination, and Interdisciplinary Group (IDG) decision-making.
• Provides feedback, education, and corrective guidance to clinicians regardingdocumentation standards and timeliness requirements.
• Provides ongoing education and training related to hospice documentation standards, regulatory requirements, quality improvement initiatives, and HOPE reporting.
• Assists with orientation and onboarding of new clinical staff related to quality and compliance expectations.
• Maintains hospice survey readiness and assists with preparation for, participation in, andfollow-up from state, CMS, and accreditation surveys.
• Reviews and recommends updates to agency policies and procedures to maintainregulatory compliance and support quality improvement.
• Collaborates with hospice leadership, clinical managers, and IDG members to support high-quality, patient-centered care delivery.
• Supports leadership in evaluating clinical performance and identifying opportunities for improvement.
• Promotes patient, staff, and environmental safety and monitors compliance with infection control and safety policies.
• Identifies and escalates safety concerns, adverse events, and potential compliance risks.
• Always ensures patient confidentiality and HIPAA compliance.
• Other duties as assigned.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and abilities required.

• Current, unencumbered Registered Nurse (RN) license in the state(s) of practice is required.
• Strong working knowledge of CMS Hospice Conditions of Participation (CoPs) is required.
• Experience with hospice documentation, IDG processes, and quality audits is…