Facility Services Regulatory Compliance Specialist

Schedule

Full-time: 40hrs/wk

Hours: Monday - Friday, Days

General Summary

Ensures evidence of Physical Environment (PE) compliance with all codes and standards required by Accrediting Organizations (AO's) or other regulatory agencies conducting surveys for the system is up to date. Formulates, updates, and maintains opportunities for improvement, and deficiencies found during audits and surveys by AO's and regulatory agencies within mandatory time frames established by those agencies.

Duties and Responsibilities

Remote Work Capable

Essential Functions:

• Performs various audits to validate Physical Environment documentation is complete and ready for survey and notifies appropriate Physical Environment Departments of audit and tracking results.
• Attends all surveys to present Physical Environment documentation at all licensed sites.
• Tracks completion of deficiencies in the mandatory timelines established by AO’s and other regulatory agencies.
• Evaluates maintenance activities necessary for compliance and inspection programs to ensure future compliance. Works with the systems engineering/maintenance managers to implement these activities and score their effectiveness.
• Assists in Corrective Action Plans of non-conformities and opportunities for improvement found during survey activities. Schedules and attends meetings related to Corrective Action Plans for various survey findings and opportunities for improvement.
• Keeps abreast of appropriate regulatory agency requirements related to accreditation, Codes or Standards. Educates others in these requirements and assist in interpretation of Codes and Standards.
• Assists in research and requesting waivers from regulatory agencies as required for Code compliance.
• Assists in maintaining storage of all survey reports and documentation by regulatory agencies, as well as supporting documentation by local Authorities Having Jurisdiction (AHJ) for previous deficiency citing’s.
• Performs audits to validate Physical Environment documentation is complete and ready for survey by reviewing Life Safety planned maintenance (PM) activities completed for the System, as necessary.
• Collaborates with consultants and regulatory agencies for interpretation on fire, life safety and other Codes or Standards for compliance.
• Creates, reviews, revises, and coordinates policy efforts and procedures regarding compliance-related activities within the Physical Environment.
• Assists in evaluating and testing various solutions for the Physical Environment to allow for more efficient data collection and planned maintenance tracking for compliance with various Codes and Standards.

Common Expectations:

• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in the Physical Environment and Life Safety compliance.
• Implements goals, objectives, and procedures for the department, which will guide and support the flow of information freely within the System.
• Provides outstanding service to all customers, foster teamwork and practice fiscal responsibility through continual personal improvement and innovation.

Required for All Jobs:

• Performs other related duties as identified.
• WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program.
• WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

Physical Demands:

• Standing - Occasionally
• Walking - Occasionally
• Sitting - Frequently
• Reaching - Rarely
• Talking - Frequently
• Hearing - Frequently
• Repetitive Motions - Occasionally
• Eye/Hand/Foot Coordination - Occasionally

Working Environment:

• Occupational Hazards - Occasionally

Travel Requirements:

• Estimated Amount: 30% - Travel to any announced and unannounced survey and internal audits at any WellSpan hospital and/or ambulatory site.

Qualifications

Minimum Education:

• High School Diploma or GED Required
• Associates Degree Preferred

Work Experience:

• 1 year Relevant experience. Required
• 3 years Relevant experience. Preferred

Driver's License Statement:

Must possess a valid driver's license in the current state of residence. Driving record must meet requirements established by WellSpan Risk Management.

Courses and Training:

• Training and Courses as assigned. within 2 years Required
• DNV CHOP-B Certification within 2 years Preferred

Knowledge, Skills, and Abilities:

• Basic computer and database skills.