Job Title:  Compliance Nurse Department: PHC – 

OSHA Class: 1 Pay Level: E5

Reports to: Director of Nursing FLSA Status: Exempt

Prepared by: Human Resource Revised Date: December 2, 2025

Approved By: DON Approved Date: 

SUMMARY: 

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

B. Quality Assurance & Performance Improvement (QAPI)

C. Documentation & Record Review 

D. Education & Staff Support.

E. Risk Management & Incident Review

F. Policy & Procedure Oversight

G. Perform other tasks as required

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 instructions. 

c. Must be able to respond to audible emergency signals, alarms, call lights and telephones. 

d. Must be able to smell smoke, spoiled food, incontinent residents, etc. 

e. Must be able to identify a resident within a reasonable distance (20 feet), focus and read thermometer, oxygen pressure gauge and similar equipment. 

f. Ability to identify colors for warning lights, signs and labels. 

g. Must be able to read regular/small size print.

3. Cognitive

a. Must be able to remember multiple assignments over an extended period. 

b. Must be able to remember specific requests, ideas and concepts and relate them as necessary. 

c. Must be able to concentrate on details during constant interruptions.

WORK ENVIRONMENT 

Works primarily indoors in a climate controlled setting. There is constant exposure to blood, body tissues and fluids with occasional exposure to hazardous materials and infectious diseases. There is exposure to loud outbursts from residents with the potential for bodily injury. There is known stress associated with working with residents who are ill, confused, irritable, irrational. There is ongoing need to handle resident death and the psychological effects associated with it. Exposure to chemicals as identified in the Hazardous Communication Log. Continuous exposure to latex, plastic and materials used for personal protective equipment.

EQUIPMENT USED

Works primarily indoors in a climate controlled setting. There is the potential for exposure to blood, body tissues and fluids with occasional exposure to hazardous materials and infectious diseases. Exposure to chemicals is occasional. There is known stress associated in working with residents who are ill, cognitively and functionally impaired.

EMERGENCY SITUATIONS

In the event of an emergency, employee must be physically able to assist in resident evacuations and to assist choking victims.