Position Summary Coordinates, evaluates, maintains, and enforces an effective SJCHS system wide facility compliance program. The program consists of document management of the Life Safety, Emergency Power, Water Management, Biomedical Equipment, and other utilities as defined by the Joint Commission. Provides oversight, coordination, and scheduling of regulation inspection and testing of facility staff, vendors and contractors to ensure safe operation and compliance to regulations and laws. Attends Environment of Care (EOC) and Emergency Management (EM) meetings, trainings, and drills. Acts as scribe for all EOC and EM minutes and notes.

Conducts safety and risk assessments, coordinating safety rounds and recording documentation of rounds. Ensures applicable NFPA codes, policies, and procedures are implemented and enforced. Communicate to hospital staff and contractors the programs, policies and procedures to ensure compliance with all regulatory agencies. Assists with code compliance in-service training. Reports problems pertaining to corrective actions regarding code issues and inspections. Collaborates with Safety and Emergency Management, Facilities, and Project, Design and Construction departments to provide standard and/or unique approaches to ensure compliance.

The Facility Compliance Coordinator will be responsible for scheduling fire alarm and sprinkler inspectors for SJCHS, ensuring that all inspections are completed on time according to the contract schedule. Responsible to record inspection, coordinate ILSM assessment with Director of Facility Management as need from the inspection, and ensure follow up on deficiencies are completed and documented. Records all documentation for regulatory compliance including state, local, CMS and Joint Commission. Collects deficiency information of the physical environment and disseminate summaries of actions and results to the EOC committee. Coordinates environmental risk assessment with SJCHS Safety Coordinator. Serves as liaison to schedule periodic inspections with local Authority Having Jurisdiction (AHJ). Collaborates with contractors and other team members to assess Life Safety risk and implement the Interim Life Safety Measures (ILSM) Serves as a member of the Environment of Care committee. Coordinates testing, inspection and repair activities of the Life Safety Systems with vendors. Must be highly organized and ability to maintain proper productivity and work flow for multiple projects. Must be a team player and able to maintain cooperative working relationships. Demonstrated sensitivity to and respect for a diverse population.

Performs secretarial, clerical and administrative services for the Facility Management Department and Director. May also be assigned other duties as needed. Education High School Diploma - Preferred Job-related course work after high school - Preferred Special training in specific areas of trade such as word processing, general repair, bookkeeping, etc. May include basic certification process. Experience 1-2 Years - Required License & Certification None Required Core Job Functions Preparation for meetings is performed in a timely manner. Minutes are transcribed promptly and sent to appropriate chairpersons/leader. Schedules meetings with co-workers and maintains manager's calendar. Assist with departmental meetings and presentations. Facilitates communication to staff timely via appropriate delivery method. Completes and passes training designated by Safety Security Management- Non-violent crisis intervention, International Association for Healthcare Security & Safety Officer, Emergency Operations Center, Decontamination, Handling of Suicidal/Homicidal Patients, self defense, restraining & takedown maneuvers and any training deemed necessary and as often by Safety Security Management. Assist with inspections of fire extinguisher, automatic sprinkler suppression components, access control and any Environment of Care related disciplines deemed necessary by Safety Security Management. Performs fire or emergency drills as requested by Safety Security Management. Completes and passes training designated by Safety Security Management- Non-violent crisis intervention, International Association for Healthcare Security & Safety Officer, Emergency Operations Center, Decontamination and any training related to the Environment of Care. Communicate, Coordinate and Implement Safety & Security reviews, debriefings on processes and events in potentially high risk situations presented in the Emergency Department. Assist with inspections of fire extinguisher, automatic sprinkler suppression components, hazardous waste containment facility, access control and any Environment of Care related disciplines. Performs fire or emergency drills as requested by Safety Security Management.