Tulsa, OK Hub
Regional Director Compliance and Survey – Hospice provides leadership and oversight to ensure agency compliance with all federal, state, and accreditation standards. This role is responsible for leading regional compliance reviews, survey readiness activities, and ongoing monitoring to safeguard adherence to CMS Conditions of Participation (CoPs), state licensure requirements, and organizational policies.
This leader serves as a resource to branch and clinical teams, ensuring proactive preparation for surveys, identification of deficiencies, and implementation of corrective action plans. The Regional Director also collaborates closely with executive leadership, Regional Director of Operations and Regional Director of Clinical Care, and branch administrators to strengthen compliance culture and maintain survey readiness across the region. This position operates within the RACI model to ensure clear communication and transparency. This role will be responsible for additional duties and assignments as the Hospice Division develops.
Key Responsibilities
Review Agency Background
- Ensure compliance with CMS Certification and State Licensure requirements.
- Oversee HR record compliance, including worker and contractor files.
- Verify compliance with governing body requirements.
- Conduct office compliance checks (signage, address verification, physical environment standards).
Clinical Records Review
- Review clinical documentation, including POCs, visit notes, and HOPE data, for:
- Timeliness
- Completeness
- Accuracy
- Compliance with CoPs
- Validate alignment of physician orders, interventions, and goals with care delivered.
Patient & Staff Interviews
- Conduct field visits with staff to perform patient interviews, assessing care quality and patient satisfaction.
- Interview interdisciplinary team members to assess knowledge of agency protocols, CoPs, and internal policies – verify compliance to IDG regulations.
Policy & Procedure Oversight
- Review compliance documentation, including:
- Infection Control Records
- QAPI Program
- Emergency Preparedness
- Performance Improvement Projects (PIPs)
- Wound Care Documentation
- Verify volunteer and bereavement programs are documented and compliant.
- Ensure that policies reflect current regulations and best practices.
Exit Reviews & Corrective Action
- Conduct exit reviews with staff and executive team members following audits or surveys.
- Review deficiencies with leadership and establish Plans of Correction (POCs).
- Collaborate with leadership to monitor implementation of corrective actions.
Performance Improvement & QAPI
- Oversee and verify adherence to quarterly and annual QAPI plans.
- Ensure continuous monitoring and reporting of compliance trends.
- Partner with leadership on initiatives to improve compliance culture and survey readiness.
Qualifications
- Licensed Practical or Vocational Nurse, Bachelor’s degree in Nursing, Healthcare Administration, or related field (Master’s preferred).
- Current RN license in good standing (preferred).
- 7+ years of compliance, quality, or survey preparation experience in hospice preferred.
- In-depth knowledge of CMS CoPs, state licensure requirements, and accreditation standards.
- Demonstrated success in leading compliance initiatives and survey readiness across multiple sites.
- Strong skills in clinical record auditing, policy interpretation, and corrective action planning.
Key Competencies
- Regulatory Expertise: Deep understanding of CMS, state, and accreditation compliance requirements.
- Attention to Detail: Ability to identify documentation deficiencies and drive corrective actions.
- Leadership: Guides teams with accountability, transparency, and collaboration.
- Communication: Effectively conveys compliance expectations to staff and executive leadership.
- Survey Readiness Focus: Maintains continuous readiness across branches, avoiding reactive compliance practices.
About Us
Why work for Central Pyramid and Affiliates?
We provide our employees with an atmosphere that will encourage them to develop their talents to their highest potential. We provide support to our employees nationwide who provide care to those in need of home health, hospice, or personal services. Join our Team to provide inspired support for our staff. We offer a welcoming professional team approach to support our field and to allow our clinicians to care for patients.
Wondering what amazing benefits we can offer you?
Full-Time Benefits
- Medical - We offer three options including PHCS PPO Plan, PHCS HSA Plan, or Preventive Plus.
- Dental and Vision - Take advantage of our Delta Dental and VSP plans!
- 401k Match - We offer a very generous 401k match!
- Paid Time Off - You will begin earning paid time off from day one! The annual average for paid time off accrual is 18 days per year to start.
- AFLAC - You can access short term disability, accident, and cancer policies through AFLAC.
Part-Time & PRN Benefits
- Medical - Part-time and prn staff are offered Preventive Plus Plan coverage.
- 401k Match - If you average over 1000 hours per year, we offer a very generous 401k match!
- AFLAC -You can access short term disability, accident, cancer policies through AFLAC.
