Facility Regulatory Compliance Coordinator

Conemaugh Nason Medical Center
Roaring Spring, Pennsylvania
Jun 11, 2024
Jun 17, 2024
Position Type
Full Time
Practice Setting
Hospital / Medical Center
Work Mode
Employment Type
Organization Type
Conemaugh Nason Medical Center is seeking a full-time Facility Regulatory Compliance Coordinator for the Maintenance and Security department. This position is responsible to ensure system and processes are in compliance with all regulatory agencies including but not limited to The Joint Commission, PA Department of Health, Roaring Spring Borough, Insurance Carriers, contracted fire protection engineering firms, and other regulatory agencies conducting surveys for Conemaugh Nason Medical Center and/or its physician practices. This position supports the medical center's commitment to comply with all federal, state, and local standards, with an emphasis on compliance. The Regulatory Compliance Coordinator develops and maintains the continuous readiness programs that contains all necessary elements to sustain regulatory compliance.

Conemaugh Nason Medical Center is a 45-bed hospital that serves rural and suburban populations in Roaring Spring, Altoona, and parts of Blair, Bedford, and Huntingdon counties. Caring for the community since 1900, Conemaugh Nason Medical Center prides itself on providing safe, high quality, compassionate care. With a state-of-the art cardiac catheterization lab, Conemaugh Nason offers a range of inpatient and outpatient cardiac services close to home when every minute matters. The hospital provides 24/7 emergency care as an accredited chest pain center, and offers comprehensive outpatient, imaging, diagnostic, and specialty services. As a LifePoint Health National Quality Leader, Conemaugh Nason is leading the way among peers by delivering the highest quality of care for patients.

Conemaugh Nason is also a member of the Conemaugh Health System, a Duke LifePoint Healthcare system. Conemaugh Health System serves more than a half-million patients each year through the Nason Physician Group, Conemaugh Physician Group and Medical Staff, a network of four hospitals, specialty clinics and patient-focused programs.

Essential Functions:

Supports exceptional clinical outcomes and patient safety using knowledge of all TJC, CMS and state licensure standards and/or regulations; uses tracer, audit and tracking tools to monitor all Conditions of Participation and DOH/TJC standards on a rotating basis throughout the year; identifies areas of high risk for more intense monitoring and intervention.

Must possess and maintain current knowledge of State, Federal and The Joint Commission (TJC) regulations related to the areas of Environment of Care, Life Safety, and Emergency Preparedness and is responsible to ensure facility compliance.

Maintains a regulatory scorecard that identifies metrics for compliance with the regulatory standards and provides reports as needed to the facility CEO, CNO, and PSO; takes an active role in resolving barriers to 100% achievement of the metrics.

Responds to inquiries by regulatory and accreditation bodies.

Conducts root-cause analyses on known DOH/TJC standards and develops action plans to address all causes in collaboration with facility leadership.

Monitors implementation of all regulatory plans of correction, reporting variances or deviation from the plan.

Reviews available quality and patient safety data to identify areas of high risk for standard deviation; develops action plans to correct deficiencies and ensures implementation and monitoring of those plans.

Works collaboratively with organizational development, infection prevention, pharmacy, plant operations, laboratory, and other disciplines to educate leaders at every level on changes in standards; incorporates changes into the regulatory compliance program.

In coordination with the facility's quality team, monitors OFIs (Opportunities for Improvement) and sentinel event reports to focus on high-risk areas that may negatively affect standards compliance.

Develops and maintains a continuous readiness program that contains all the necessary elements to maintain regulatory compliance; reviews the integrity of the program over time, reporting concerns and barriers to compliance; seeks continuous improvement.

May participate in leadership rounding to engage with caregivers and front-line employees responsible for meeting standards.

Coordinates regulatory and accreditation survey activity (i.e. TJC, CMS, DOH, and/or mock survey activity); Participates in all Life Safety surveys and building tours.

Prepares Annual Evaluation of the seven Environment of Care Plans to present to the Safety Committee and Governing Board.

Develops, coordinates, facilitates, and maintains CNMC disaster/emergency/EOC management plans; ensures all staff are competent in emergency/disaster management preparedness.

Develops, implements, and coordinates facility-wide emergency trainings; prepares and delivers appropriate training to all staff of CNMC.

Coordinates and conducts drills in cooperation with the CNMC EOC and local officials as needed.

Maintains positive relationships with federal, state and local emergency response groups, including local fire, law enforcement, EMS providers and other emergency management groups.

Ensures effective and immediate communication with Senior Management during an emergency or disaster (i.e. impending storms requiring Senior Management to respond to events).

Keeps abreast of changes to laws and regulations that impact CNMC, utilizing best practices in emergency management and planning; attends meetings, conferences and workshops related to emergency/disaster management.

Serves on the Environment of Care (EOC) Committee; Assists in preparation of items for the meetings; Prepares the agenda; Acts as the chairperson in the absence of the chair for the meetings.

Maintains current Emergency/Disaster Preparedness/EOC and Life Safety policies in PolicyStat, revising as necessary.

Maintains Safety Data Sheets (SDS) in all required areas throughout the facility; ensures all SDS are up to date at all times, revising as needed.

Acts as and functions as the maintenance and security/plant ops department secretary by answering the department phone, assisting with coordination of duties and tasks, contacting vendors and contractors, typing memos, and maintaining online/computer systems and programs for the department, etc.

Orders supplies to ensure efficiently functioning facilities department.

Reports all incidents, accidents, hazardous conditions or equipment to the Maintenance and Security Manager or Director, Facility Operations/Maintenance.

Inspects work areas and equipment frequently for safety, fire protection and prevention, etc.

Ensuring promoting a safe environment in all actions.

Ensure effective communication and delegation of duties, as needed, when absent from the facility.

Maintain privacy and confidentiality of records, conditions and other information relating to patients, employees, and the facility.

Organizational Expectations:

Recognizes own limitations and seeks help from appropriate sources when needed.

Maintains compliance with federal and state regulations and employment laws.

Adheres to Corporate Compliance Guidelines and requirements of Federal, State, and local regulatory and accrediting agencies with no deviation from standards.

Attends mandatory annual in-services with no deviation from departmental time frames.

Attends departmental meetings/in-services as scheduled with no unexcused absences.

Participates in continuing education programs as per job classification requirements.

Presents a professional image by appearance, articulation, and behavior; adheres to hospital and departmental dress codes, including wearing the Nason ID badge, with no pattern of deviation.

Is dependable with infrequent call-offs and appropriate use of PTO and according to Hospital policy; must maintain punctuality; Must provide a minimum of one (1) hour notice for unscheduled absences; Routine attendance at work is an essential function of the position.

Respects the cultural and diversity, rights, privacy needs of the patients, employees, and all whom we come in contact with no deviation of hospital policy.

Adheres to standards of professional ethics and maintains confidentiality regarding all patient and all privileged work information with no documented deviation from standards.

Demonstrates support of the mission, vision values, goals, and general policies of Nason Medical Center.

Minimum Education:
High School Diploma or GED is required.
Associate's degree in computer science, Business Management or related field is preferred.

Minimum Work Experience:
Minimum of three (3) years of experience in a professional, business office environment; Three (3) years of experience with proficiency in Microsoft Computer Applications (i.e. Word, Excel, Power Point) is required.
Minimum three (3) years of experience with Facility Operations database and Regulatory Compliance documentation; Quality Control Experience; Certified Healthcare Compliance through Compliance Certification Board is preferred.

Required Skills:
Strong ethical conduct and professional demeanor.
Strong computer skills required, proficiency in applications.
Has knowledge of and maintains competencies with the TJC, CMS, DOH, state licensure standards and/or regulations.
Ability to understand tracers; management of tracers and databases as needed.
Ability to analyze complex data, identify trends, and build collaborative action plans to proactively resolve risk factors click apply for full job details