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Under the supervision of the Chief Nursing Officer, is responsible for, but not limited to, developing and implementing quality improvement activities, supporting essential nursing, education, and reporting needs, and promoting compliance with regulatory requirements pertaining to quality of care issues.


  1. Conducts scheduled on-site medical record reviews as established by the Quality Assessment Performance Improvement plans.
  2. Provides guidance and education to nursing and other clinical staff on required corrective actions as a result of medical record reviews.
  3. Supervises assigned staff.
  4. Develops/recommends internal caregiving policies and procedures to address new or changing needs and/or services.
  5. Coordinates/conducts or assists with customer satisfaction activities including survey and complaint review.
  6. Recommends, develops and implements outcome-based quality of care studies and assists with Root Cause Analysis projects.
  7. Completes data collection, entry and reports of Performance Improvement Projects and other improvement activities for presentation at the Nursing Services Committee meetings.
  8. Completes Hospice Item Set data submissions and reports documentation discrepancies as applicable to DPCQ.
  9. Educates and mentors new nursing employees on Electronic Medical Record and other hard copy documentation as applicable.
  10. Assists the nursing department with home care, hospice, or palliative care admissions or other RN care visits as needed.
  11. Conducts discipline specific orientation, basic and on-the-job training and in-service for employees regarding confidentiality, customer rights, policy and procedures and quality improvement activities.
  12. Serves as a staff resource regarding policy and procedures, governmental regulations and quality improvement issues.
  13. Assists in the development and the execution of corrective action plans pertaining to the QI department as a result of regulatory survey.
  14. Assists with aide training programs, including Supervised Practical Training, employee orientation, and other educational support as applicable or directed.
  15. Serves on agency committees as may be assigned.
  16. Maintains an obligation to report wrongdoing/violation of agency policies, applicable federal, state and local laws, and regulations, pertaining to agency operations, to immediate supervisor or identified compliance officer.
  17. Adheres to and reflects organizational values in daily work.
  18. Completes all mandatory in-service education programs and completes any other additional in-service hours that are minimally required for the position.

The above examples of work may not be a complete statement of all assignments that may be inherent to the position.  Other duties may be assigned as deemed necessary and appropriate by the Director of Patient Care Quality and/or CEO.


  1. Current New York State nursing license and registration as a registered professional nurse.
  2. Two years nursing experience, one year preferably in-home care.
  3. Demonstrated organization skills.
  4. Effective verbal and written communication skills.
  5. Computer literacy and the ability to work effectively with electronic medical records.
  6. Acceptable driver’s license and automobile available for use with current insurance.        
  7. Successful completion of NLN proficiency in medication administration exam.
  8. Availability by telephone.

Interested candidates can send resumes and cover letters to:

For any questions or for more information, please contact Human Resources at (716) 372-2106