What are the responsibilities and job description for the Regional Director Compliance Survey HH position at Mays Home Health?
TULSA, OK HUB
Position Summary
Regional Director Compliance and Survey – Home Health 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 Home Health 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 OASIS 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
• 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.
Oversee all Home Health data and reporting, and implement key data points at the branch level in partnership with the Operations Team to ensure regulatory and best practice care delivery and optimal outcomes for every patient.
