SUMMARY

Under the direction of the Director of Facilities Management, this position is responsible for all regulatory compliance documentation relating to Joint Commission, Center for Medicaid and Medicare Services (CMS), Fire Department, Insurance Carrier, etc. Also responsible for compliance with these agencies by all service contracts related to work performed by outside vendors/service providers. Works with Directors, managers and supervisors ensuring guidelines are followed and documentation is filled appropriately. Monitors and tracks all work performed by internal and external resources to ensure contract conditions are met and inspection documentation and reports are obtained.

Job Responsibilities

Reviews and files appropriate documentation for all work performed to include documentation for fire alarm system, fire sprinkler system, halon/ansul system, fire extinguishers, fire pumps, fire sprinkler standpipes, fire department connections, fire alarm monitoring, rollin fore doors, smoke/fire dampers, ventilation testing, isolation room monitors, laboratory hood certification, generator testing, battery operated light testing, medical gases alarm panel testing,

Reviews service reports to identify any trending and problems. Analyzes data and recommends to management appropriate course course of action, i.e. , repair, replace, change vendor, etc.

Performs all other duties as assigned

Coordinates and schedules required inspections, testing and certification for regulatory compliance with vendors and end users/customers

Monitors and inspects the work performed by vendors and service providers to ensure the contract requirements are being met.

Review plans and documents for all new construction to ensure compliance with GHS Design Standards, TJC and CMS standards, conducts pre-construction Risk, ILSM and ICRA assessments, documents requirements and monitors including daily checklists for compliance

Reviews content of contracts with appropriate staff to ensure required function/tasks are included

Maintains accurate and up to date files for all documentation related to regulatory compliance

Identifies costs associated with required inspections, testing and certifications and assists management in the budget process

Develops an annual schedule of all service contracts, establishing the effective and expiration dates. Reviews documentation received from service providers to ensure required information is contained in the reports

Tracks annual service contract schedule to ensure renewals are processed before expiration. Submits appropriate paperwork associated with renewing service contracts.

Education

Required:

Bachelor's Degree in Safety, Risk Management, Industrial Hygiene or Science or related from an accredited higher education institution. Minimum of 7 years of relevant healthcare experience, to include 5 years in leadership will be considered in lieu of a Bachelor's degree

Experience

Required:

A minimum of 7-10 years of healthcare or fire/life safety experience is required

Previous experience in compliance inspections or healthcare accreditation

3-5 years in leadership, supervisor level and above

Skill/Cert/Licenses

Required:

Must possess superior organizational, interpersonal and time management skills, be self motivated and have strong verbal and written communication skills

Must be knowledgeable of the Joint Commission, Occupational Safety and Health Administration (OSHA), National Fire Protection Association (NFPA) regulations and model safety programs strategies/survey processes.

Knowledge and experience with use of computer and related software programs, as well as demonstrated experience data collection, data analysis and reporting

Valid Georgia driver license or the ability to obtain one within first 90 days

Preferred:

Experience n managing and enhancing database platforms