Facility Compliance - Life Safety Specialist

Job Description

The Facility Compliance / Life Safety Specialist consults with the leadership responsible for managing the DNV NIAHO Physical Environment (PE) management plans. The Specialist assists in overall process improvement, record review, reporting, analysis, data, and any other relevant programs and activities affected by regulations and standards. The Specialist also makes recommendations to change procedures or practices that are out of compliance with stated regulations and implements plans to address such changes.

SHIFT AND SCHEDULE

Full Time: 8:00 AM – 5:00 PM

ESSENTIAL FUNCTIONS/PERFORMANCE EXPECTATIONS

Quality Assurance

• Analyzes potential regulatory risks within Facilities, Food and Nutrition, Environmental Services, Security, Construction, Disaster Preparedness and Clinical Engineering to ensure compliance with codes and standards.
• Develops, review, implements, and updates policies, facility survey readiness activities and procedures to ensure compliance with applicable laws, regulations and standards which may include CMS Conditions of Precipitation, DNV standards, OSHA, NFPA, etc.
• Analyzes databases, records, reports, operating practices, and other documentation to identify opportunities for process improvement, trending, and compliance, requiring knowledge across a variety of software platforms.
• Develops and implements plans to address issues in quality, safety and compliance for Food and Nutrition, Environmental Services, Security, Facilities, Construction, Disaster Preparedness and Clinical Engineering.
• Maintains current understanding of applicable codes and standards from a variety of regulatory authorities, through participation in educational opportunities ranging from industry literature and white papers to symposiums, conferences, and personal networking in professional organizations.
• Conducts periodic departmental internal quality audits within Food and Nutrition, Environmental Services, Security, Facilities, Construction, Disaster Preparedness and Clinical Engineering departments.
• Communicates audit progress and findings through report preparation in coordination with key stakeholders.
• Conducts regular audits, inspections and assessments to monitor compliance with regulations and standards. maintenance of documentation and formulates plans of action to ensure compliance. Assists DNV NIAHO Physical Environment management plan champions in formulating corrective action plans, including root cause analyses for findings cited during annual DNV accreditation surveys.
• Maintains and participates in RCA’s as needed for Food and Nutrition, Environmental Services, Security, Facilities, Clinical Engineering, Disaster Preparedness, and Construction.
• Serves as the Scribe for for Accreditation survey, and works closely with the surveyors during annual accreditation, as well as other department certification surveys that apply to the Environmental Services, Security, Facilities, Clinical Engineering, Disaster Preparedness, and Construction if necessary.
• Ensure Environmental Services, Security, Facilities, Clinical Engineering, Disaster Preparedness, and Construction staff competency of performance improvement measures through training and coaching.
• Assists leadership from Food and Nutrition, Environmental Services, Security, Facilities, Clinical Engineering, Disaster Preparedness, and Construction with Quality Management System reporting for the Performance Improvement Committee and Quality Management Oversight Committee.

Safety

• Assists the Hospital Safety Officer in the event of the activation of the Incident Command System.
• Performs the duties of Department Safety Officer (DSO) and Chemical Hygiene Officer for Facilities, Construction, and Clinical Engineering, including education, presentations, rounding, and internal safety practices.
• Assists in the training programs to ensure all staff member receives training materials.
• Assess the effectiveness of the training programs and makes adjustments as necessary.
• Assists the EVS, Security, Food and Nutrition, and Disaster Preparedness DSOs with quarterly DSO compliance requirements.
• Acts as Liaison to Disaster Preparedness Coordinator and Document Control committee.
• Membership in Governing Body entities; NFPA, ASHE, AAMI, and ASHRAE.

Physical Environment

• Acts as Co-Chair of the Physical Environment Committee and facilitates all committee meetings.
• Responsible for taking and transcribing minutes for Physical Environment Committee as well as assembling packets and sending out meeting reminders and data requests.
• Acts as Team Lead for one of the PE rounding teams.
• Representative of PE Committee at all management committee meetings; PIC, Patient Safety, and QMSOC.
• Ensures and maintains documentation for annual DNV surveys such as Life Safety, Utility Management, Lockout-Tagout, Hot Work Permits, and equipment calibration certifications.
• Champion of the NIAHO PE.3 Safety Management Plan. As management plan champion, responsible for tracking, trending, and reporting monthly performance. indicator data to the Physical Environment Committee. Must also comply with standards under the Safety Management System.
• Assists Food and Nutrition, Environmental Services, Security, Facilities, Clinical Engineering, Disaster Preparedness, and Construction department leadership in formulating corrective action plans, including root cause analyses for findings during Internal and Physical Environment Committee audits.
• Conducts regular departmental rounding to identify areas of non-compliance in Food and Nutrition, Environmental Services, Security, Facilities, Clinical Engineering, Disaster Preparedness, and Construction.
• Prepares and distributes rounding reports to department directors.
• Consults with department leadership to identify areas of non-compliance and works with department management in Food and Nutrition, Environmental Services, Security, Facilities, Clinical Engineering, Disaster Preparedness, and Construction to develop action plans for other Quality Management Oversight Committees.
• Assists department Directors from Food and Nutrition, Environmental Services, Security, Facilities, Clinical Engineering, Disaster Preparedness, and Construction with annual NIAHO document review within Policy Tech.

Life Safety

• Stays abreast of changes in life safety regulations and standards.
• Ensure the facility adheres to all applicable life safety codes and standards
• Implement necessary updates to policies and procedure to maintain compliance.
• Assists in the comprehensive and up to date life safety program, to include reports, and all associated documentations.
• Conducts periodic inspections for above ceiling penetrations.

Administrative

• Utilize the Verge Software system for compliance and incident reporting.
• Attention to detail, strong communication skills, analytical and decisions making skills are necessary.

EDUCATION AND EXPERIENCE

• High school diploma or equivalent required. · Associate’s degree preferred but not required. · The following certification is preferred but not required. Healthcare Accreditation Certified Professional (HACP) and Certified Healthcare Operations Professional (CHOP) or comparable certifications.

PHYSICAL REQUIREMENTS

To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The individual must be able to:

• Stand, walk, sit, stoop, reach, lift, see, speak and hear. Lifting is limited to 35 lbs. for clinical staff and to 50 lbs. for non-clinical staff. The individual must use an assisted-lift device or get another individual(s) to assist with the lift that is over these maximum limits.