E00809 – Facilities Regulatory Readiness Specialist
Works collaboratively with all RCA partners (internal and external) to ensure policies, procedures and processes reflect compliance with all regulatory regimes in which we operate, are operationalized and actionable in terms of appropriate levels and qualifications of staff, technology/systems and other critical factors necessary to function in a compliant, safe and sound manner to the benefit of our patients and employees. The Facilities Regulatory Readiness Specialist is responsible for assisting the Corporate Compliance and Nursing Manager and Vice President of Facilities in maintaining survey readiness at all RCA facilities to ensure that all state and federal regulatory requirements are consistently met; the incumbent must be able to interact and maintain a dialogue with all relevant regulatory services in connection with regulatory submissions; must develop and maintain solid working relationships with RCA leaders to help facilitate survey readiness, effective complaint handling/reporting and notifications; professionally represent the company during audits and inspections of the company and our quality systems.
- Position is part of the Survey Readiness team and is responsible to audit compliance for all RCA service lines.
- Participate on site at RCA conducted mock survey readiness audits and assist the facility leadership team with developing appropriate corrective action plans that mitigate risk and meet standards.
- Participate in new facility walk through preparations and planning as need to ensure regulatory compliance is met in their area of expertise.
- Audit responsibilities will include but not limited to ensuring sites are adhering to Federal, State, local and RCA policies related to: Emergency Management, Environment of care and all Facilities related safety inspections.
- Participate in the development and annual reviews also attend monthly emergency management / EOC meetings
- Provide support as needed during onsite surveys.
- Participates with the Survey Readiness Team and supports scheduled surveys and ad hoc projects to streamline regulatory processes.
- Advise both internal and external partners on regulatory matters and requirements and provide guidance on meeting those requirements
- Advise and strategize with senior leadership, keeping them informed of regulatory developments and advising them on methods to execute contingency methods to reflect best practices.
- Maintain excellent records and create methods to quickly address potential violations.
- Strategize with team in the development of new and existing policies for the continual improvement of efficiency in regulatory compliance.
- Collaborate with key stakeholders any pertinent information related to Compliance to assist in addressing any deficiencies noted and impact with relationship to company policy and procedures.
- Interact with QA colleagues at facility sites to assist with workloads and/or to troubleshoot Operations-related issues.
- Collaborate with other departments in the development and streamline processes to facilitate policy and procedure compliance.
- Effectively communicate with appropriate Federal, State and local contacts on regulatory matters in order to ensure we remain in compliance with current standards.
- Audits of EOC and life safety necessary inspection for their completeness and compliance.
- Audits of required drills such as Fire, emergency preparation.
- Work with site leadership to set standards around documentation for emergency preparedness drills
- Participate and Patient Safety and Quality reviews as well at Root Cause Analysis as required
- Will be involved in a new construction installs to ensure all proper safety contracts in in place
- Will be involved in existing construction projects to ensure any changes to the physical plant is safe and complaint for safety.
- Will help train new facilities managers on all compliance regulatory bodies ie: ( JACHO -CARF State and local authorities)
- Other duties as assigned.
Education and Experience:
- Minimum of an associate degree or 5 years working in a facilities management capacity
- Experience working in a healthcare environment.
- Direct knowledge of JACHO standard as it relates to behavior health
- Experience with working with state and local governing bodies
- Working knowledge of Microsoft Word, Excel, and Outlook.
Customer Service: Demonstrates concern for meeting internal and external customers’ needs that provides satisfaction for the customer within the resources that can be made available.
Impact and Influence: Works effectively with and through others including those whom there is no formal authority over.
Project Management: Coordinates the diverse components of the project by balancing scope, time, cost, and quality.
Communication: Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.
Work Environment: May work in a variety of environments including professional offices, clinics, hospitals, or out-patient facilities. They spend much of their time on their feet, actively working with patients.
Physical Demands: While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands to finger, handle or feel objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move objects up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.
Travel: Travel is expected 70% of the time and will require some out-of-the-area and overnight travel.