Nursing Program Compliance Nurse

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage.

Brief Job Description:

Come work in an environment where we truly value and respect those we serve and believe in the mission that all people can achieve a higher level of wellness and independence.

The state supported living centers serve people with intellectual and developmental disabilities who are medically fragile or who have behavioral problems. The centers provide campus-based direct services and supports at 13 centers located throughout the state. Learn About Our State Supported Living Centers

If you are looking for a place to work where you can establish a career that is filled with purpose, this is the job for you!

Free CEUs and updated resources through Lippincott access for all nurses.

The Nursing Program Compliance Nurse (Nurse III) performs duties within the scope of practice attributed to the skills of a registered nurse and reports to the Chief Nurse Executive (CNE). Coordinates and organizes nursing services and activities related to nursing program compliance. Oversees nursing processes to ensure quality data is collected in order to create an accurate clinical picture of nursing services provided to individuals served. Audits files, analyzes data, develops nursing trend reports, and makes recommendations to address trends and deficiencies. Develops the nursing department monitoring and audit tools, in conjunction with state-office discipline coordinator. Develops, reviews, and explains policies, procedures, protocols related to nursing program and nursing program compliance. Plans and oversees the nursing department’s preparation, involvement and response to internal and external monitoring visits. Creates and reviews reports. Plans, develops, implements, and monitors nursing services compliance programs and processes. Makes rounds to observe processes, provide coaching to staff and to collect data. Attends and provides information at assigned meetings. Serves as lead investigator for alleged violations to the Texas Nursing Practice Act as assigned. Provides direct care nursing services as needed and other duties as assigned. Provides treatment to HHS employees injured in course and scope of employment. Works under limited supervision with considerable latitude for the use of initiative and independent judgement.

This position may be eligible to earn additional pay for work performed on evenings, nights and/or weekends.

Essential Job Functions (EJFs):

Attends work on a regular basis and may be required to work a specific shift schedule or, at times, even a rotating schedule, extended shift and/or overtime in accordance with agency leave policy and performs other duties as assigned. Serves in the nursing on-call rotation as assigned.

[May serve in an on-call status on a rotating schedule as required to meet operational needs of the facility.]

Coordinates and organizes nursing services and activities related to nursing program compliance. Completes and/or oversees the completion of required reports and documentation. Monitors, reviews and audits nursing records, such as nursing care plans and nursing assessments for compliance with policies, procedures, protocols and guidelines to promote best practices for quality of care. Collects and analyzes data to develop nursing trend reports for review and approval by the CNE and presentation at the Quality Assurance/Quality Improvement (QAQI) meeting. Summarizes findings and provides recommendations for actions to be taken to address trends and deficiencies.

Oversees processes to ensure data is obtained in order to provide an accurate clinical picture of nursing services provided to individuals served. In conjunction with state-office discipline coordinator, develops the nursing department monitoring and audit tools such as those used for document reviews/audits and quarterly and annual assessments. Disseminates tools to designated subject matter experts monitoring findings and tracking through completion. Ensures there is interrater reliability by bringing findings together from multiple sources to review for consistency. Enters the information generated from tools into local or statewide tracking systems as appropriate, so that the data can be tracked and analyzed. Ensures analysis of auditing and recommendations are shared with applicable nursing administration members. Routinely collaborates with nursing administration team to develop corrective actions and measure progress towards improved compliance. Updates and revises tools as necessary such as when policies, procedures and guidelines change.

Develops, reviews, and explains policies, procedures, protocols related to nursing program and nursing program compliance in conjunction with the CNE and/or State office discipline coordinator.

Assists in developing guidelines for the nursing program compliance nurse position as assigned. Makes recommendations to the CNE/NOO on how to improve processes to ensure quality services for individuals. Ensures monitoring and audit tools align with nursing policies, procedures and guidelines. Cross trains at least one designee to perform nursing program compliance duties. Makes recommendations for, and assists with, changes to nursing policies, procedures and protocols to enhance the quality of services and compliance with requirements.

Plans, develops, implements, and monitors nursing services and processes such as those for the safe administration of medications and medication room protocols. Makes SSLC rounds in accordance with a schedule and as determined by the needs of the SSLC to ensure that prescribed methods and procedures are followed during medication administration. Gathers and performs data analysis on medication variances, medication pass observations and medication room audits, as assigned. Participates in monthly meetings to discuss data and determine corrective action when needed.

Plans and oversees the nursing department’s preparation and response to regulatory survey, Department of Justice (DOJ) Settlement Agreement and other internal and external monitoring visits. Pulls documents and reviews documents pulled by others for sufficiency and correctness before submission to monitors and auditors. Provides quality assurance checks for the nursing department to ensure all documents are of good quality and provide a comprehensive and responsive package of information. Participates in the review process as assigned such as participating in medication observations and providing feedback to nurses on identified concerns, performing interrater reliability tasks, and demonstrating the SSLCs ability to provide self-monitoring. Reviews written reports provided by auditors and monitors and provides comments and recommended edits. As assigned, develops, implements, and tracks nursing quality improvement plan(s) to improve quality of care and address issues noted in monitoring reports.

Attends and provides information at assigned meetings such as Root Cause Analysis (RCA) and medication variance meetings. QAQI departmental nursing meetings, and state-wide compliance nurse meetings. At the direction of the CNE, attends training to become a Level I certified investigator in order to serve as lead investigator for alleged violations to the Texas Nursing Practice Act at the SSLC, as assigned. Presents investigative findings to the peer review committee, or chairs the committee, as assigned by the CNE and in accordance with Board of Nursing requirements.

Provides consultation, training, and technical assistance to the subject matter experts such as Nurse Managers, Nurse Educators, and other specialty nurses to effectively use the monitoring and auditing tools. Collaborates with the Nurse Educator to develop educational materials and provide education to nurses on such topics as Quality Improvement Plans (QIPs), Corrective Actions Plans (CAPs), areas of deficiency within the nursing department and what is needed to address deficiencies. Collaborates with the Nurse Educator on new employee orientation and ongoing training and development. Provides direct, real time feedback and coaching to nurses when performing documentation audits, such as reviewing nursing care plans, to improve their skills and the quality of services. Conducts outreach activities to other departments within the SSLC or to external entities, providing information sessions as assigned such as during a recruitment event or skills development fair.

Provides direct care nursing services as needed. Administers medication, immunizations, and treatment, and observes patients for unusual symptoms and reactions. Provides treatment to HHS employees injured in course and scope of employment.

Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.

Knowledge, Skills and Abilities (KSAs):

• Considerable knowledge of nursing techniques, standards, and procedures; of health care laws and regulations; of medical diagnoses and procedures; of accepted medical treatment patterns; of community health and nursing care principles, practices, and procedures; of program regulations and procedures; and of utilization review and control measures.

• Knowledge of nursing care standards, the Settlement Agreement, and the Healthcare Guidelines or ability to quickly gain the knowledge.

• Knowledge of state and federal laws and Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) rules, regulations, policies, and procedures related to SSLCs or ability to quickly gain that knowledge.

• Knowledge of emergency procedures and emergency equipment, i.e., Cardiopulmonary Resuscitation (CPR), and ability to assess and care for residents and/or staff members in emergency situations.

• Skill in the use of computer/software and an electronic health record system.

• Skill in writing policy, procedures and guidelines.

• Excellent verbal and written communication skills and the ability to present ideas clearly and concisely in both written and oral communications.

• Skill in the care and treatment of patients.

• Ability to provide patient care; to prepare and maintain records; to organize, coordinate, and evaluate nursing activities and delivery of health services; to interpret policies and procedures; to interpret health care regulations; to recognize patterns of medical necessity treatment; and to provide technical assistance and consultation to others.

• Ability to identify trends, analyze data and maintain spreadsheets and databases.

• Ability to interpret regulations and communicate them effectively both orally and in writing.

• Ability to appropriately interact with individuals with intellectual/developmental disabilities, with their family members, and with staff members.

• Ability to work independently and productively with all levels of staff.

• Ability to train/in-service all levels of staff.

• Ability to make recommendations to SSLC leadership including on-call administrators.

• Must maintain current CPR certification. Must have strength and flexibility to safely perform CPR.

Registrations, Licensure Requirements or Certifications:

Licensed to practice as a registered nurse in the State of Texas (or a state that recognizes reciprocity through the Nurse Licensure Compact).

Initial Screening Criteria:

• At least one (1) year experience as a practicing registered nurse is required.

• At least two (2) years of experience as a practicing registered nurse in a health agency, hospital, or health-care facility is preferred.

• Quality Assurance monitoring experience is preferred.

• Bachelor's Degree is preferred.

• Previous experience working with Individuals with Intellectual and/or Developmental Disabilities (IDD) is preferred.

Additional Information:

Applicants must pass a fingerprint criminal background check, pre-employment drug screen, and registry checks including the Client Abuse/Neglect Reporting System (CANRS), Nurse Aide, Medication Aide and Employee Misconduct and HHS List of Excluded Individuals/Entities (LEIE).

Males between the ages of 18 – 25 must be registered with the Selective Service.

All State Supported Living Center Employees are subject to Random Drug Testing.

Flexibility in work hours may be required for this position. The position may be required to work overtime and/or extended hours. Must be willing to work weekends and holidays.

All applicants must be at least 18 years of age to be considered for employment at a state-operated facility.

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Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form