Director of Nursing

Key Responsibilities

• Develops and annually reviews agency-wide policies and procedures related to nursing practice, infection control, and patient care to ensure compliance with current standards and regulations.
• Makes written and oral reports/recommendations to the Administrator, as necessary, concerning the operation of the clinical service department.
• Develops, implements, and maintains an ongoing quality assurance program for the clinical service department.
• Ensures timely and accurate completion of discharge summaries for all clients exiting services.
• Reviews Infection Control/Occurrence Reports for all clients. Provides / documents all follow up related to Infection Control/Occurrence Reports (both client and employee) and processes these reports.
• Conducts site visits and audits to ensure adherence to nursing standards.
• Leads Continuous Quality Improvement (CQI) initiatives and implements corrective action plans.
• Participates in committee activities as requested.
• Prepares, implements and supports emergency preparedness planning and implementation.
• Assists in the implementation and monitoring of the agency’s Corporate Compliance Program to ensure ethical and legal operations.
• Serves as a liaison between clinical staff and administration.
• Participates in committee activities and strategic planning.
• Promotes a culture of collaboration, respect, and continuous improvement.
• Holds weekly Case Conferences to discuss client issues.
• Determines if clients that are planned for discharge meet the requirements for Management and Evaluation or any other skilled service.
• Holds bi-weekly KPI meetings to ensure all Key Performance Issues are addressed and issues are resolved.
• Reads and adheres to all Agency Policies and Procedures and follows the Employee Handbook Guidelines.
• Collaborates with the marketing team to promote the agency’s clinical capabilities and service excellence.
• Participates in community outreach events and professional gatherings to build relationships with referral sources.
• Represents the agency in meetings with hospitals, physicians, and community partners to foster trust and referral growth.
• Supports strategic initiatives aimed at expanding the agency’s visibility and reputation in the service area.
• Maintains licensure and health status requirements.
• Participates in continuing education and leadership training.
• Evaluates personal performance and sets development goals.
• Stays informed of changes in healthcare regulations, payer requirements, and insurance industry trends to ensure agency compliance and adaptability.

Regulatory Compliance & Accreditation

• Prepares for and participates in agency surveys and inspections.
• Prepares for and keeps ready all necessary documentation as required by Regulatory Agencies and Surveyors.
• Ensures documentation meets standards for ADR and denial review.
• Maintains confidentiality and integrity of patient and employee information.
• Adheres to and participates in Agency’s mandatory HIPAA / Privacy Program and Employee Compliance Program.
• Ensures compliance with CMS Conditions of Participation, CHAP standards, and HIPAA regulations.
• Reviews Infection Control/Occurrence Reports for all clients.
• Provides / documents all follow up related to Infection Control/Occurrence Reports (both client and employee) and processes these reports.
• Conducts site visits and audits to ensure adherence to nursing standards.
• Maintains confidentiality and integrity of patient and employee information.
• Ensures compliance with CMS Conditions of Participation, CHAP standards, and HIPAA regulations.

Staff Management & Development

• Recruits, trains, and evaluates clinical and clerical staff.
• Conducts performance appraisals and progressive disciplinary actions.
• Ensures adequate staffing levels and monitors absenteeism.
• Counsels employees on performance issues.
• Coordinates regular in-services and other regular trainings and ongoing education.
• Provides orientation for new hires.
• Provides training as needed.
• Oversees TB testing and documentation for new and existing staff.
• Ensures initial and annual competency assessments for all clinical and non-clinical field staff, including CHHAs, are completed and documented.
• Terminates employment of personnel when necessary, documenting and coordinating such actions with the Governing Body and Administrator.
• Performs site visits of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards.
• Assures site visits are completed for therapy personnel.
• May function as a staff nurse during emergencies or staffing shortages.

Intake & Referral Management

• Maintains PECOS certification verification for referring physicians.
• Reviews and processes Non-Admit cases per agency protocol.
• Provides administrative On-Call support to ensure continuity of operations during off-hours.
• Maintains documentation readiness for surveys and audits.
• Reviews and follows up on Complaint Forms and Quality Improvement (QI) reports to ensure resolution and documentation.
• Ensures consistent onsite supervision of nursing staff to maintain clinical standards and support staff performance.
• Follows up on all referrals, through admission and billing processes.

Leadership & Communication

• Serves as a liaison between clinical staff and administration.
• Participates in committee activities and strategic planning.
• Promotes a culture of collaboration, respect, and continuous improvement.
• Holds weekly Case Conferences to discuss client issues.
• Determines if clients that are planned for discharge meet the requirements for Management and Evaluation or any other skilled service.
• Holds bi-weekly KPI meetings to ensure all Key Performance Issues are addressed and issues are resolved.
• Reads and adheres to all Agency Policies and Procedures and follows the Employee Handbook Guidelines.

Marketing & Community Engagement

• Collaborates with the marketing team to promote the agency’s clinical capabilities and service excellence.
• Participates in community outreach events and professional gatherings to build relationships with referral sources.
• Represents the agency in meetings with hospitals, physicians, and community partners to foster trust and referral growth.
• Supports strategic initiatives aimed at expanding the agency’s visibility and reputation in the service area.

Professional Development

• Maintains licensure and health status requirements.
• Participates in continuing education and leadership training.
• Evaluates personal performance and sets development goals.
• Stays informed of changes in healthcare regulations, payer requirements, and insurance industry trends to ensure agency compliance and adaptability.