Job Summary

This position plans, coordinates, implements and evaluates facility(ies)/entity(ies) and regulatory programs for preparedness and accreditation/certification/licensure requirements. This position acts as a subject matter expert to leadership, staff and system teams/work groups as related to regulatory requirements to ensure standards are met. Work processed by the incumbent is confidential and protected from discovery by subpoena pursuant to state, department of health services, the Joint Commission and CMS regulations.

Essential Functions

• Responsible for the implementation of regulatory requirements using standardized regulatory processes in one or more facilities/entities. Prepares facilities/entities for surveys by evaluating standardized infection prevention/control and Environment of Care (EOC)/Life Safety (LSC) regulatory processes. Reviews, evaluates and assists in the development and implementation of of facility/entity policies, procedures and guidelines as they relate to regulatory compliance. Makes recommendations on all facility matters related to compliance with Joint Commission, CMS, national/ state/local regulations and/or professional standards.

• Conducts observations, tracers, building tours, document reviews and interviews to ascertain facility compliance with standards, rules and regulations. Documents findings and provides facility with reports and recommendations for change. Completes and updates the Joint Commission application.

• Provides direction and education to facility functional team leads on completion of the Periodic Performance Review, standardized metrics and action plans for resolution of identified non-compliance with regulations and standards. Provides tools for ongoing measurement and reporting of compliance with regulatory standards. Supports development and monitors completion of facility plans of correction. Oversees and assists functional teams and department managers in the development of corrective actions.

• Responds to notices of surveyor arrival at facilities by directing survey management activities, clarification of standards, support and assistance to the senior leadership team. Initiates and directs post survey activities to ensure the facility meets regulatory process requirements. Schedules and participates in unannounced corporate surveys system-wide. Works with facility leadership and staff to prepare for survey readiness. Identifies and coordinates compliance activities of regulatory content experts such as infection control and EOC/LS specialists.

• Provides support and guidance to responders to life safety, environment of care, emergency management and infection control events. Evaluates events to ensure standards and regulatory requirements are not compromised.

• Reports to senior leadership on compliance trends and recommends improvement strategies. Presents data and reports deficiencies identified during internal observations/tracers, and the status of implementation of action plans to senior leadership and at facility regulatory meetings. Reports facility survey readiness status on an ongoing basis. Updates senior leadership on system regulatory compliance trends and certification/accreditation bodies most frequently scored standards.

• Serves as a subject matter expert on internal and external regulatory standards. Provides education to address regulatory changes and gaps in regulatory compliance. Provides guidance to leaders and staff to ensure they understand regulatory requirements. Serves on assigned committees, as chair or co-chair as appointed. Schedules and maintains regulatory meetings, updating the committees on current and future plans and procedures, capabilities and actions. Chairs the facility function team and is actively involved in the regulatory workgroup.

• Maintains regulatory expertise through independent study as well as attending education workshops, tracking and reviewing regulatory changes, reviewing professional publications, establishing personal networks, and participating in professional societies.

Minimum Qualifications

Requires knowledge as typically obtained through a Bachelors degree in nursing or other healthcare related field.

Requires a strong knowledge of regulations and standards within area of focus as typically attained with 5 years relevant experience in a hospital setting, plus 3 years regulatory experience. Requires the ability to manage programs, projects and databases. Requires demonstrated excellence in interpersonal and written communication skills. Must possess demonstrated flexibility in responding to the needs of multiple constituencies with a service oriented philosophy. Demonstrated ability to lead and facilitate interdisciplinary teams. Requires ability to perform complex statistical analysis and highly developed problem solving skills.

Preferred Qualifications

Prior experience with in a surveyor role and experience in process improvement, regulatory/accreditation programs, data management and analysis, including graphic development and presentations is also preferred. For clinical assignments, current clinical license/certification preferred. For life safety and environment of care assignments, Certified Safety Professional (CSP), Certified Health Care Safety Professional (CHCSP) or similar certification preferred.

Additional related education and/or experience preferred.