Compliance Nurse

Compliance Nurse

The Compliance Nurse is responsible for ensuring the facility maintains full adherence to all federal, state, and organizational regulations, policies, and standards. This role supports quality assurance, survey readiness, risk reduction, and clinical excellence by monitoring compliance, conducting audits, identifying areas for improvement, and coordinating corrective action plans. The Compliance Nurse serves as a resource and coach for clinical staff, promoting safe, consistent, and regulatory-compliant care throughout the facility.

A. Regulatory Compliance & Survey Readiness

· Maintain working knowledge of CMS regulations, and state guidelines

· Conduct routine audits of documentation, assessments, medication administration, infection control, and other clinical processes.

· Support survey readiness efforts, including mock surveys, staff preparation, and ongoing compliance monitoring.

· Participate in survey activities and assist with formulating and implementing plans of correction (POCs).

B. Quality Assurance & Performance Improvement (QAPI)

· Assist with the development, tracking, and evaluation of QAPI initiatives.

· Monitor performance indicators and trends to reduce risk and improve resident outcomes.

· Participate in committees such as QA, Risk Management, Infection Control, and Safety as assigned.

C. Documentation & Record Review

· Review clinical documentation for accuracy, timeliness, and regulatory compliance.

· Provide feedback to nursing and interdisciplinary team members to ensure consistent and complete documentation practices.

· Ensure physician notification, care plans, assessments, and interventions align with regulatory expectations.

D. Education & Staff Support

· Provide ongoing training and coaching to staff regarding compliance expectations, best practices, and regulatory updates.

· Support new staff onboarding with compliance-related education.

· Serve as a resource to nursing and leadership on regulatory interpretation and policy adherence.

E. Risk Management & Incident Review

· Participate in investigation of incidents, grievances, and reports to identify root causes and corrective measures.

· Monitor for patterns or trends that may indicate compliance risks.

· Support follow-up actions and verify completion of corrective steps.

F. Policy & Procedure Oversight

· Assist in the development, revision, and implementation of facility policies.

· Ensure staff understanding and adherence to updated policies and procedures.

Qualifications

1. Ability to read/write comprehensive English and document observations.

2. Must perform basic math.

3. Ability to verbally communicate with residents, staff and general public in a manner that is understandable, must be honest, dependable and exhibit a warm, cheerful, caring manner.

4. Must be able to safely perform the essential functions of the job with or without reasonable accommodation.

Education and/or Experience

1. Requires current nursing License in good standing on file with the Indiana Nursing Board. RN preferred

2. 2-3 years' experience in long-term care or other health care setting preferred

3. Knowledge of CMS regulations, state survey processes, and healthcare compliance standards.

4. Strong attention to detail, organizational skills, and ability to work independently. Excellent communication, teaching, and coaching abilities.

5. Experience with audits, QAPI, survey readiness, or risk management is preferred

Physical Demands

1. Physical

a. Will need to continuously stand and walk, squat, bend to floor, reach, twist, sit and potentially remain in uncomfortable positions for extended periods of time.

b. Must be able to lift, move and turn residents. Requires varying degrees of pushing, pulling and lifting depending on the weight of the resident, which is often times over 100 pounds.

c. Must have eye/hand coordination sufficient to assist residents with ADL's, transfers, and ambulation.

d. Must be able to clearly speak.

e. Must deal calmly with multiple tasks, noises, and interruptions on a continuous basis.

2. Sensory

a. Must be able to hear normal sounds and voice patterns with constant background noise.

b. Must be able to receive and follow verbal…