Facility Regulatory Compliance Coordinator

2 weeks ago

Roaring Spring, United States Conemaugh Nason Medical Center Full time

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 re

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