Compliance Nurse

Job Title: Compliance Nurse

OSHA Class: 1

Pay Level: E5

Reports to: Director of Nursing

FLSA Status: Exempt

Prepared by: Director of Nursing

Revised Date: October 22, 2026

SUMMARY:

The Compliance Nurse is responsible for ensuring the facility maintains full

adherence to all federal, state, and organizational regulations, policies, and

standards. As well the maintenance and retention of medical files for patients and

residents in accordance with the Indiana State Department of Health. 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. The Compliance nurse must stay

up to date on new laws including but not limited to, Medicare, Medicaid, Dept. of

Health, HIPAA, Elder Justice, etc. Compliance nurse is also responsible for an

array of other tasks such as auditor of electronic charting and immunization

records.

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. Medical record

H. 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.

G. Medical records

• Admission chart – prepare chart with each admission and distribute to Admissions Coordinator. Assist with obtaining photograph of newly admitted resident within 48 hours to be downloaded to EMAR. Point Click Care demographics checked with resident credentials for accuracy in transposition. Assist with obtaining and maintaining resident inventory sheet as needed.
• Admission Audit – completed within 24-48/72 hours after admission and re-audit within (14) days after admission, which includes initial departmental assessments, completed, and immunization including flu, pneumonia, and Mantoux. Initial nurse entries, vitals, medicare certifications, diagnoses, and review Advance Directives to ensure accuracy.
• On-going Audits – correctable chart audits: physicians, nursing staff and other health care professionals to flag these deficiencies for completion by the appropriate persons, audit records on a regular basis for omissions in documentation. Chart audits to be completed on admission, quarterly, and at discharge as needed.
• Thinning/filing – Monthly, all charts require thinning of Physician Orders, Pink Progress Notes, Telephone Orders, Controlled Substance Record, Nurses Notes, MAR,TAR, Behavior/Intervention Monthly Flow Record, Glucose and IV records, Therapies, I&O records. Ensure these are uploaded into Point Click Care for accuracy.
• Order - Forms that are needed through vendors; When needed, these forms are ordered and tracked through P.O and approved by administrator or DON prior to ordering.
• Storage of Paper Charts- Manages storage of paper charts as indicated by State and Federal Regulations. Assists with destruction of old charts as needed.