Director of Nursing

Director of Nursing (DON) – Home Health Care Agency

Position Summary

The Director of Nursing (DON) is responsible for the oversight and coordination of all clinical services within the agency. This includes ensuring compliance with federal, state, and accreditation standards (CMS, CHAP), maintaining high-quality patient care, supervising clinical staff, and supporting strategic initiatives. The DON also plays a key role in intake management and referral source engagement to ensure smooth patient onboarding and continuity of care.

The Home Health Director of Nursing Services functions under the direct supervision of the Administrator and the general supervision of the Governing Body.

Key Responsibilities

Clinical Oversight & Quality Assurance

• 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.
• Develops, maintains, and periodically updates the Clinical Service Procedures Manual and clinical service objectives and philosophies.
• Develops and implements a clinical service organization structure.
• 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.
• Assures that the client’s plan of care is executed as written and reassessed by the appropriate health care professional when there is a significant health status change in the client’s condition, at the physician’s request and after hospital discharge. Further assures appropriate documentation is completed for all patients transferred to an inpatient facility.
• Periodically reviews clinical records to ensure completeness, accuracy, and compliance with agency standards, including SOC, Advance Directives, and Plan of Care documentation.
• Ensures timely and accurate completion of discharge summaries for all clients exiting services.

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.
• Responsible for ADR and Denial review, preparation and submission per established protocols.
• 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.
• Leads Continuous Quality Improvement (CQI) initiatives and implements corrective action plans:

Develops corrective plans congruent with the COP and Policies and Procedures. Routes the corrective plan to the Administrator. Reviews approval and implements corrective plan.

1. Completes QI forms monthly for QI data collection and submits to Administrator and Implements corrective plan as appropriate. 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.

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.
• 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

• Monitors referral sources and collaborates with marketing and intake teams to optimize patient acquisition.
• Facilitates the intake process, ensuring timely documentation, eligibility verification, and coordination with physicians.
• Oversees software systems for intake tracking, evaluation packet review, and visit scheduling.
• Ensures 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.

Administrative & Financial Duties

• Reviews and approves payroll transmittals and accounts payable.
• Participates in budget planning and resource allocation.
• Maintains documentation readiness for surveys and audits.
• Performs administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.
• Stays abreast of current economic conditions/situations and recommends adjustments to the Administrator/Governing Body to assure that the objectives of the facility can be maintained.
• Supervises day-to-day office and clinical operations to ensure continuity of care and task completion, including during staff absences.
• Generates and maintains the monthly On-Call Schedule to ensure 24/7 clinical coverage.
• Reviews the On-Call Log daily to monitor after-hours issues and ensure timely follow-up.
• 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.
• Responsible for conducting general staff meetings.
• Holds weekly Case Conferences to discuss client issues. Determine 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.
• Provides clinical input for marketing materials to ensure accuracy and alignment with agency standards.
• 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.

And, other duties as requested or required by Supervisor.