Engineering Reg Compliance Coordinator in Hobart, Indiana at Powers Health

St. Mary Medical Center, Hobart, Indiana

Position Summary

Under the supervision of the Director of Engineering, the Engineering Regulatory Compliance Coordinator, supports the design, monitoring, analysis and improvement of environment of care. Ensures compliance with all applicable Joint Commission, Indiana State Department of Health, Indiana Department of Environmental Management, Environmental Protection Agency, and any other regulatory agency standards which involves the Department of Engineering. Works to maintain a favorable accreditation and licensure.

Job Responsibilities

• Provides regulatory coordination and support to the Engineering Division at St. Mary Medical Center.
• Reviews Life Safety reports and coordinates the resolution of deficiencies identified.
• Completes documentation for Interim Life Safety Measures and performs Risk Assessments for areas when current Life Safety Standards cannot be met.
• Prepares quarterly and annual evaluation of the Environment of Care to include Safety, Life Safety, Security, Hazardous Material and Waste, Equipment Management and Utilities.
• Work with the department directors/managers in the Engineering/Support Services Division in the establishment of performance indicators. Provides analysis and visual demonstration of statistical data for use in department meetings and various hospital committees.
• Facilitates performance improvement teams/activities, monitors and tracks project status from initiation to completion and secures documentation.
• Reviews and maintains the Electronic Statement of Conditions and tracks implementation and completion of deficiencies within the designated time frame to adhere to Joint Commission standards.
• Establishes and manages quality measures to ensure that newly constructed and existing environments are designed and maintained to comply with the Life Safety Code®.
• Obtains and maintains Hazmat certification to approve the disposal of hazardous materials and waste in coordination with government regulations.
• Meets with JC, ISDH, IDEM and IDOT Surveyors, along with engineering staff in response to all inspections and citations.
• Conducts follow-up coordination of action and documentation on all recommendations identified by external surveyors that pertains to Environment of Care and/or Life Safety.
• Represents Engineering/Support Services on the following committees: Safety and Disaster, Infection Control, Hospital Quality Management, Quality Council and Patient Care Safety Subcommittee.
• Provides quality reports and regulatory updates concerning Environment of Care at the Safety and Disaster Committee meetings.
• Participates in the hospital building tours and provides feedback to assessed departments.
• Provides recommendations to the budget as it relates to regulatory compliance and patient/staff/visitor safety.
• Utilizes word processing, Excel, PowerPoint, Automated CAMH, AIMS, Internet/Intranet and Outlook Express in accomplishing Quality Improvement functions.
• Supports compliance to all IDEM and EPA regulations for air quality which include quarterly, semi-annual and annual documentation and assists with on-site inspections.
• Coordinates with the Engineering department managers/supervisors to ensure timely completion of Leadership Evaluation Manager and monthly Operational Excellence reports.
• Completes a preliminary review of all policies and procedures at SMM and recommends changes as needed.
• Establishes, participates and manages mock tracer schedules and tours for continual readiness at SMM.

Education/Experience

• Minimum Bachelor’s Degree, Healthcare or Engineering degree preferred.
• Minimum of 5 significant (TJC, ISDH, EPA, IDEM) Regulatory Agency Surveys
• Minimum 10 years experience in a regulated industry, no less than 5 years in Healthcare
• Strong organizational and documentation skills required
• Must be personable, able to work in a professional atmosphere and have a cooperative attitude.

Comprehensive Benefits Program (Not all inclusive)

• Medical, dental and vision coverage
• Healthcare and Dependent Care Spending Accounts
• Retirement savings plan
• Life insurance and disability coverage options
• Fitness center discount program
• Tuition assistance and career development
• Paid Time Off
• Wellness, reward and recognition programs
• Employee Assistance Program – Counseling, nutritional and financial education, etc.
• Perks - Instant Discounts & Exclusive Deals on hotels, food, clothing, etc.

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