JOB PURPOSE:
The primary purpose of the Compliance Verification Mock Survey Senior Nurse Consultant is to support long-term care centers in achieving and sustaining regulatory compliance by conducting mock surveys, identifying areas of risk, and guiding teams through proactive quality improvement. This role is critical in preparing facilities for state and federal inspections and ensuring delivery of high-quality, person-centered care.
KEY RESPONSIBILITIES:
1. Conduct facility-wide mock surveys aligned with CMS and state regulatory standards, including clinical, environmental, and life safety areas.
2. Identify potential deficiencies and provide detailed reports with actionable recommendations for correction and improvement.
3. Review clinical documentation (MDS, care plans, assessments, medication administration records) for accuracy and compliance.
4. Coach and educate facility teams including Administrators, Directors of Health Service, and Interdisciplinary teams on survey processes compliance expectations and documentation standards.
5. Assist with the development and implementation of Plans of Correction and ongoing Quality Assurance Performance Improvement strategies.
6. Monitor follow-up on previous survey deficiencies to ensure sustained compliance
7. Provide real-time feedback, modeling, and mentoring during survey readiness walkthroughs.
8. Participate in regulatory readiness calls, trainings, and clinical leadership meeting
9. Participate in regulatory readiness calls, trainings, and clinical leadership meetings.
10. Stay connected with CMS regulations, interpretive guidance, and best practices in long term care compliance
KNOWLEDGE, SKILLS, ABILITIES:
• Comprehensive understanding of CMS State Operations Manual, particularly
F-tag
• Strong grasp of infection prevention and control, abuse prevention protocols, pressure injury staging, psychotropic medication monitoring and resident right
• Familiarity with electronic health record and documentation best practice
• Strong auditing, analytical and critical thinking skills to identify gaps in compliance.
• Strong verbal and written communication skills to effectively educate and guide partner
• Training and facilitation skills to support knowledge transfer and behavior change.
• Proficiency in preparing survey readiness tools, tracking systems, and summary reports.
• Ability to foster a non-punitive, solutions-focused environment during mock survey (Compliance Verification)
• Ability to work both independently and collaboratively across multiple facilitie
• Ability to manage competing priorities and travel to various facilities as needed.
• Ability to adapt quickly to changes in regulations and internal priorities.
Qualifications:
MINIMUM EDUCATION REQUIRED:
Graduate of an accredited educational institution with a degree in Nursing
Continuing education in regulatory compliance, infection control, or Quality Assurance Performance Improvement is a plus.
MINIMUM EXPERIENCE REQUIRED:
Minimum of 3-5 years of clinical experience in a long-term care or skilled nursing facility
At least 2 years of leadership experience (Director of Health Services, Assistant Director of Nursing, Quality Nurse, or Clinical Consultant).
Prior experience conducting mock surveys or participation in state/federal survey processes (preferred)
Familiarity with Plans of Correction, Quality Assurance Performance Improvement programs and compliance audit
MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
• Must possess an active Registered Professional Nursing License (multi-state)
• Infection Preventionist certification preferred, but not required
• CPR Certification
ADDITIONAL QUALIFICATIONS: (Preferred qualifications)
• Ability to analyze data, identify trends and implement improvement strategie
• Strong understanding of care coordination, patient experience and quality improvement principle
• Ability to lead and manage teams across multiple location
• Communication, leadership, and interpersonal skill
