DIRECTOR OF QUALITY & COMPLIANCE

Apis Services Inc•Cañon City, CO

14d•$90,000 - $115,000•Onsite

About The Position

The Director of Quality of & Compliance for Southern Peaks provides consultation and technical assistance to specific programs within the Abraxas Youth & Family Services (AYFS) division regarding licensing, contractual, and accreditation compliance, policy development/implementation, data collection/analysis, best practice transfer, and the implementation of an effective process for on-going monitoring and evaluation of programs. This person is also responsible for ensuring licensing, contractual, and accreditation compliance for his/her assigned programs.

Requirements

Master’s degree in social sciences, healthcare or related field and five years of quality and compliance experience or bachelor’s degree in social sciences, healthcare or related field and seven years’ quality and compliance experience
Proficiency with CO licensing and regulatory standards
Ability to effectively supervise employees
Extensive hands-on experience preparing residential behavioral health programs for Joint Commission accreditation and re-accreditation surveys, including mock tracers, standards interpretation, documentation audits, readiness planning, and corrective action plan (CAP) development.
Demonstrated mastery of Behavioral Health Care (BHC) standards, including Leadership, Environment of Care, Emergency Management, Infection Control, Patient and staff rights, Workplace violence prevention, Human Resources, and Documentation.
Proven ability to lead programs through survey remediation, implement sustainable compliance frameworks, and conduct internal tracer methodologies to maintain continuous accreditation readiness.
Advanced expertise in administration and implementation of PREA standards applicable to juvenile residential environments, including staffing plan reviews, background screening and hiring requirements, staff training, youth education protocols, incident response procedures, and sexual safety audits.
Experience leading annual PREA audits and corrective action management, including policy alignment, facility walkthrough preparation, documentation compilation, evidence submissions, corrective action tracking, and coordination with DOJ-certified PREA auditors.
Proven ability to operationalize PREA compliance across multidisciplinary teams while strengthening youth safety culture and risk-mitigation practices.

Responsibilities

Ensures licensing, contractual, and accreditation compliance, in conjunction with the quality & compliance specialist, program director, and leadership team.
Works with the quality & compliance specialist and program directors to prepare for licensing inspections, contractual reviews, and accreditation surveys.
Reviews all action plans to address licensing, contractual, and accreditation citations or areas of non-compliance before submission to ensure quality and consistency; monitors the implementation of action plans to ensure compliance.
Conducts an annual internal audit to ensure program practices meet licensing, contractual, and accreditation requirements; lead team member during the departmental audits that occur within the division.
Provides effective supervision to the quality & compliance specialist in his/her assigned programs, providing technical assistance and education on licensing, contractual, and accreditation standards.
Develops monitoring systems with the program's quality & compliance specialist to ensure licensing, contractual, and accreditation compliance and consistent implementation of program and divisional policies, procedures, and protocols.
As needed, prepares meeting agendas, coordinates meetings, maintains meeting minutes, and develops other documentation related to on-going monitoring and evaluation of the program.
Collects and maintains data; prepares reports, data displays, charts, graphs, and other illustrations.
Provides technical assistance and education to the program staff on licensing, contractual, and accreditation standards, including as-needed in-service training regarding the implementation of licensing, contractual, and accreditation standards.
Develops and maintains the AYFS operational policy & procedure manual; ensures that each program maintains a policy and procedure manual.
Participates in various internal and external committees/projects; assuming a lead role on some committees/projects.
Works with programs to implement divisional process improvements, evidence-based curricula, and program procedures/protocols.
Provides technical assistance to AYFS Development Department by working on RFP's.
Provides technical assistance and education to employees of the AYFS administrative office.