Clinical Operations Executive Assistant to the Director of Nursing (DON)

Job Description

Job Description

Job Title: Clinical Operations Executive Assistant to the Director of Nursing (DON)

Position Summary

The Clinical Operations Executive Assistant to the Director of Nursing (DON) provides advanced administrative, clinical coordination, and regulatory support within a long-term care facility. This role is integral to ensuring compliance with New York State Department of Health (NYS DOH) and Centers for Medicare & Medicaid Services (CMS) requirements, including adherence to federal regulations under 42 CFR §483 (Requirements for Participation for Long-Term Care Facilities).

Acting as an extension of the DON, this position supports clinical oversight, survey readiness, quality improvement initiatives, and interdisciplinary communication to promote safe, effective, and resident-centered care.

Key Responsibilities

Executive & Clinical Administrative Support

· Provide high-level administrative and clinical support to the DON, including calendar management, regulatory meeting coordination including spearheading meeting minutes, and prioritization of clinical issues.

· Prepare and maintain survey-ready documentation, reports, policies, and meeting materials in accordance with NYS DOH and CMS standards.

· Maintain strict confidentiality in compliance with HIPAA regulations.

· Other duties as assigned

Regulatory Compliance & Survey Readiness

· Assist in ensuring ongoing compliance with CMS Conditions of Participation (42 CFR §483) and NYS DOH regulations for skilled nursing facilities.

· Coordinate and participate in survey preparedness activities, mock surveys, and plan of correction (POC) development.

· Track and monitor Statements of Deficiencies (Form CMS-2567) and ensure timely submission of corrective actions.

· Maintain documentation for audits, including infection control, staffing, and quality metrics.

· Other duties as assigned

Clinical Operations Coordination

· Support daily nursing operations, including staffing coordination to meet minimum staffing requirements and acuity needs.

· Assist in clinical audits (e.g., documentation, medication administration, infection control practices).

· Collaborate with unit managers to ensure compliance with care standards and documentation protocols.

· Other duties as assigned

Quality Assurance & Performance Improvement (QAPI)

· Support the facility’s QAPI program in alignment with CMS and NYS DOH requirements.

· Collect, track, and analyze quality indicators, including falls, pressure injuries, infections, and hospital readmissions.

· Assist in developing performance improvement plans and monitoring outcomes.

· Other duties as assigned

Infection Control & Safety Monitoring

· Assist the Infection Preventionist and DON in maintaining compliance with infection control regulations, including CDC and CMS guidance.

· Track and report infection surveillance data and support outbreak management protocols.

· Other duties as assigned

Communication & Liaison

· Serve as a liaison between the DON, interdisciplinary team members, physicians, residents, families, and external agencies.

· Support communication related to regulatory updates, policy changes, and clinical initiatives.

· Other duties as assigned

Data Management & Reporting

· Maintain accurate and up-to-date clinical and regulatory records.

· Generate reports related to staffing (e.g., PBJ reporting), incidents, and quality measures.

· Support electronic health record (EHR) documentation compliance and audits.

· Other duties as assigned

Qualifications

Education & Licensure

· Associate’s degree or higher in Nursing or Healthcare Administration preferred.

Experience

· Minimum 3–5 years of clinical experience in a skilled nursing facility or long-term care setting.

· Prior experience with regulatory compliance, survey processes, or quality improvement preferred.

· Experience supporting nursing leadership or working in a supervisory/administrative capacity strongly preferred.

Knowledge & Skills

· Strong working knowledge of CMS regulations (42 CFR §483) and NYS DOH requirements.

· Familiarity with survey processes, CMS-2567, and Plan of Correction (POC) development.

· Proficiency in EHR systems and Microsoft Office Suite.

· Excellent organizational, analytical, and communication skills.

· Ability to manage multiple priorities in a fast-paced, highly regulated environment.

Work Environment

· Long-term care/skilled nursing facility setting with frequent regulatory oversight.

· May require extended hours during NYS DOH or CMS surveys, audits, or outbreak situations.

Reporting Structure

· Reports directly to the Director of Nursing (DON).

Key Competencies

· Regulatory and compliance-driven mindset

· Clinical knowledge applied to administrative functions

· Attention to detail and survey readiness focus

· Strong interpersonal and leadership support skills

· Ability to handle confidential and sensitive information

#upstate123