Facilities Regulatory Specialist

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A Brief Overview
The Facilities Regulatory Specialist assists the Facilities Maintenance Manager and maintains a continuous state of preparation for all Facilities accreditation, compliance and regulatory surveys enterprise-wide. The candidate also assists in developing plans of action and coordinating follow up activities from surveys. Demonstrates the application of clear, accurate and current understanding of Joint Commission (TJC), Department of Health (DOH), and CMMS requirements, to allow for accurate and timely identification of elements in the Physical Environment (PE) (formerly Life Safety (LS) / Environment of Care (EOC)) needing correction. This is an onsite position with travel to off-sites as needed.

What you will do

• Coordinates various reports for Supervisors, Managers, and Directors, etc. as requested through the (CMMS) Computerized Maintenance Management System. Coordinates the following reports by weekly, monthly, quarterly or semi- annual reports: Create new/update Benchmarking reports, Regulatory Preventive Maintenance equipment reports, Regulatory-EOC, PM performance completion reports. Life Safety codes reports-responsible for compiling documentation required for regulatory agencies. Enter/Document Preventive Maintenance inventory and equipment in the CMMS.
• Oversee all Facilities Accreditation Documentation. Process specific reports for TJC and DOH documentation. Maintains organized files according to departmental procedures. Assist in maintaining on site licensing documentation at CHOP campuses and other satellite sites. Participate in scheduled and unscheduled Regulatory Compliance reviews with multiple Authorities Having Jurisdiction (AHJ) presenting data and compliance documentation. This may occur at multiple locations throughout the year.
• Onsite visits to various CHOP locations and campuses. Compile and organize regulatory documentation. Develop documentation punchlists for sites. Maintain regulatory documentation.
• Review regulatory documentation from vendors for completeness and accuracy. Assemble meetings with vendors and CHOP staff and provide guidance and recommendations on needed documents and regulatory information.
• Represents Facilities and participates in Physical Environment rounding and surveys throughout the enterprise. Collaborates and participates in meetings with Regulatory Accreditation Team as needed.
• Reviews Basic Building Information (BBI) and Statement of Condition (SOC) drawings for accuracy and compliance with field conditions including fire and smoke resistant barriers and compartments.
• Submit Facilities Maintenance projects as required through DOH portal. Coordinate any DOH responses/ follow up surveys.
• Participates in Joint Commission and DOH surveys throughout the enterprise; both physical touring and document review. Prepare plans of correction on identified deficiencies.
• Supports Facilities Maintenance in other areas as needed.
• Supports Project Management, Real Estate, and Planning Teams as needed.

Education Qualifications

• High School Diploma / GED - Required
• Bachelor's Degree - Preferred

Experience Qualifications

• At least five (5) years Life Safety/EOC regulatory compliance in a healthcare setting - Required

Skills and Abilities

• Proficient with Microsoft Outlook, Excel, Word, PowerPoint, Teams and Sharepoint (Required proficiency)
• Knowledge of Joint Commission standards, FGI guidelines, NFPA standards, including NFPA 101 Life Safety Code and NFPA 99 Health Care Facilities Code (Required proficiency)
• Knowledge of Joint Commission and Department of Health surveys (Required proficiency)
• Knowledge of CMMS database applications and reports, preferably Archibus. (Required proficiency)
• Strong writing, editing and proof-reading skills required. (Required proficiency)
• Ability to work independently with minimal supervision. (Required proficiency)
• Ability to use personal judgment and initiative to develop effective and constructive solutions to barriers to policy development/revision activity and process. (Required proficiency)
• Ability to be pro-active in following up on projects and tasks. (Required proficiency)
• Ability to handle confidential materials. (Required proficiency)
• Ability to handle multiple tasks and priorities. (Required proficiency)
• Excellent organizational skills. (Required proficiency)
• Knowledge of regulatory terminology and protocol. (Required proficiency)
• Excellent interpersonal and communication skills between multiple levels of leadership (Required proficiency)

Licenses and Certifications

• Certified Healthcare Facility Manager (CHFM) - American Society for Health Care Engineering (ASHE) - upon hire - Required

To carry out its mission, CHOP is committed to supporting the health of our patients, families, workforce, and global community. As a condition of employment, CHOP employees who work in patient care buildings or who have patient facing responsibilities must receive an annual influenza vaccine. Learn more.

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SALARY RANGE:

Salary ranges are shown for full-time jobs. If you're working part-time, your pay will be adjusted accordingly.

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At CHOP, we are committed to fair and transparent pay practices. Factors such as skills and experience could result in an offer above the salary range noted in this job posting. Click here for more information regarding CHOP's Compensation and Benefits.