Director of Compliance

Mission Statement:  The Salvation Army, an international movement, is an evangelical part of the universal Christian Church. Its message is based on the Bible. Its ministry is motivated by the love of God. Its mission is to preach the gospel of Jesus Christ and to meet human needs in His name without discrimination.

 

Position Summary:

 

The Director of Compliance is responsible for developing, implementing, and overseeing the organization’s compliance to ensure adherence to federal, state, and local regulations, accreditation standards, and internal policies. This role ensures that the facility’s operations meet all clinical, ethical, and legal requirements, protecting clients, staff, and the organization’s reputation.

 

Essential Responsibilities:

• Develop, implement, and maintain a comprehensive compliance program in line with federal (HIPAA, CARF), state, and local regulations at all 3 Harbor Light sites.
• Draft, review, and update organizational policies and procedures to ensure they reflect current regulations and best practices.
• Oversee all accreditation processes (e.g., CARF and others as applicable) and serve as the primary point of contact for all related matters, ensuring continuous compliance with accreditation standards across all programs.
• Establish and maintain a hard stop EMR system to ensure record compliance.
• Serve as the primary point of contact for regulatory agencies, auditors, and accrediting bodies (CARF, state licensing boards).
• Conduct internal audits of clinical and operational practices, including documentation, billing, patient records, and medication handling.
• Track corrective actions and follow-up to ensure compliance gaps are addressed promptly.
• Prepare for and coordinate external audits, site visits, and accreditation surveys.
• Develop and deliver staff training programs on compliance, ethics, patient rights, and confidentiality.
• Provide ongoing education about regulatory updates and emerging compliance issues.
• Coordinates staff training on quality standards, documentation best practices, and regulatory compliance top maintain a culture of continuous improvement and service excellence.
• Investigate compliance-related incidents, breaches, or complaints; recommend corrective action.
• Oversee reporting requirements for adverse events, sentinel events, and mandated disclosures.
• Oversee the regulatory agencies database and input data for the application process and monitor the data input for citation clearance.
• Implements corrective action plans in response to internal audits licensing visits, accreditation reviews, or other quality findings.
• Routinely monitors corrective measures to ensure ongoing compliance.
• Regularly evaluates service delivery against contractual obligations to ensure full compliance with finding requirements. Identify and address any discrepancies in performance.
• Maintain up-to-date knowledge of regulatory developments and emerging trends in behavioral health and homelessness to ensure organizational compliance and service relevance. 
• Designs, and implements and takes leadership of the command center during any survey activity.
• Collaborate with clinical leadership to mitigate risk and improve patient safety.
• Collect and analyze compliance data, prepare reports for the Executive Director, Quality Assurance Committee, Divisional Finance Board (DFB).
• Monitor trends in compliance, patient care outcomes, and regulatory changes to proactively adjust organizational practices.

 

Qualifications:

Education/Experience: 

• A master’s degree in business or health/human services field, Licensed Registered Nurse, or bachelor’s degree with equivalent experience.
• Minimum of seven years of experience in the SUD/Behavioral Health sector
• Minimum of two years of management experience in the SUD/Behavioral Health sector
• Three to five years of compliance background in SUD/Behavioral Health preferred.
• Possess a working knowledge of addiction recovery
• Valid Michigan Chauffeur License and approved by The Salvation Army MVR
• TB. test, police clearance, and MDOC LEIN clearance required