Director of Quality Assurance and Infection Prevention

POSITION SUMMARY:

The Quality Assurance / Infection Prevention Nurse (RN) is responsible for supporting the facility's quality assurance and performance improvement (QAPI) activities and for leading the facility's infection prevention and control program. This position serves as the facility's designated Infection Preventionist (IP) in accordance with 42 CFR 483.80 (F880 through F883), with sufficient dedicated time to fulfill the infection prevention and control responsibilities of the role. The QA/IP Nurse works collaboratively with nursing leadership, department heads, the Medical Director, and the consultant pharmacist to promote resident safety, prevent healthcare-associated infections, and drive measurable quality outcomes in a long-term care setting.

KEY RESPONSIBILITIES:

Quality Assurance & Performance Improvement (QAPI)

•         Support the facility's QAPI program in accordance with 42 CFR 483.75, including data collection, analysis, and reporting for QAPI and Quality Assessment and Assurance (QAA) meetings.

•         Monitor and trend clinical indicators, including CMS Quality Measures, CASPER reports, falls, wounds, weight loss, hospitalizations, and medication events.

•         Assist in developing and monitoring Performance Improvement Projects (PIPs) with measurable goals and timelines.

•         Conduct routine clinical chart audits, documentation reviews, and compliance rounds; report findings with recommended corrective actions.

•         Participate in mock surveys and survey readiness activities; assist with implementation and monitoring of plans of correction.

•         Track and trend incident reports and adverse events; assist with root cause analyses and follow-up on corrective action plans.

•         Contribute quality and infection control data to the annual Facility Assessment (42 CFR 483.71).

Infection Prevention & Control (Designated Infection Preventionist)

•         Develop, implement, and annually review the facility's Infection Prevention and Control Program (IPCP), including written standards, policies, and procedures based on nationally recognized guidelines (CDC, CMS, APIC).

•         Conduct ongoing facility-wide infection surveillance using standardized definitions (e.g., McGeer/revised McGeer criteria); track, trend, and analyze healthcare-associated infections.

•         Lead outbreak identification, investigation, management, and reporting, including line listings, cohorting/isolation strategies, and communication with staff, residents, and families.

•         Report communicable diseases, outbreaks, and required data to the Alabama Department of Public Health and submit required data through the CDC's National Healthcare Safety Network (NHSN).

•         Oversee implementation of standard and transmission-based precautions, including correct selection and use of personal protective equipment (PPE).

•         Conduct routine infection control audits and competency observations, including hand hygiene, PPE use, catheter care, wound care, laundry, dietary, and environmental cleaning and disinfection practices.

•         Serve as a core member of the facility's antibiotic stewardship program; monitor antibiotic use, review cultures and antibiograms, and promote appropriate prescribing in collaboration with the Medical Director and consultant pharmacist.

•         Manage the employee health program as it relates to infection control, including TB screening, immunization tracking, exposure follow-up, and work restriction/return-to-work guidance for ill staff.

•         Administer the resident influenza, pneumococcal, and COVID-19 immunization programs, including education, consent, documentation, and offer/refusal tracking (F883).

•         Collaborate with maintenance and environmental services on the facility water management program and environmental infection control