Compliance Coordinator

Lake Cumberland Regional Hospital

Who We Are:

People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Lake Cumberland Regional Hospital is a modern, state-of-the-art 295-bed acute care facility, offering an advanced neurosurgery program with Spine Center accreditation amongst other specialty services.

Where We Are:

The City of Somerset blends southern hospitality with abundant recreational opportunities including a 65,000-acre lake with 1,200 miles of shoreline. Somerset is host to nationally recognized, high quality performing and visual arts, concerts and other special events to the community.

Why Choose Us:

• Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
• Competitive Paid Time Off / Extended Illness Bank package for full-time employees
• Employee Assistance Program - mental, physical, and financial wellness assistance
• Tuition Reimbursement/Assistance for qualified applicants
• Professional Development and Growth Opportunities
• And much more

Position Summary:

A Compliance Coordinator 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, Insurance Carriers, contracted fire protection engineering firms, and other regulatory agencies conducting surveys. 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.

Reports to:

FLSA: Non-Exempt

Job Requirements

Minimum Education: Required: High School Diploma or GED, Preferred

Associates Degree in Computer Science, Business Management or related field, Preferred

Minimum Work Experience:

a. Required: Minimum of three (3) years of experience in a professional, business office environment; Three (3) years of experience with proficiency in Microsoft Computer Applications (i.e. Word, Excel, Power Point)

b. Preferred: Minimum three (3) years of experience with Facility Operations database and Regulatory Compliance documentation; Quality Control Experience; Certified Healthcare Compliance through Compliance Certification Board is ideal

Required Skills

a. Strong ethical conduct and professional demeanor.

b. Strong computer skills required; proficiency in applications.

c. Has knowledge of and maintains competencies with the TJC, CMS, DOH, state licensure standards and/or regulations.

d. Ability to understand tracers; management of tracers and databases as needed.

e. Ability to analyze complex data, identify trends, and build collaborative action plans to proactively resolve risk factors.

f. Ability to communicate clearly, proactively, and concisely with all levels of management and staff and patients; effective listening skills.

g. Ability to manage multiple tasks and prioritize actions required to quickly resolve issues and maintain high levels of productivity, sustaining long working hours when necessary.

h. Exceptional customer service skills.

i. Ability to work closely and professionally with many different departments.

j. Ability to plan, coordinate, and lead projects.

k. Strong initiative to influence events and achieve goals; self-starter; proactive.

l. Detail oriented with a high degree of knowledge of essential duties.

m. Ability to organize workload, adapt quickly to change, provide accurate information, and deliver under the pressure of deadlines; strong organizational skills.

n. Ability to work in a team-oriented environment, develop and maintain cooperative working relationships, as well as work independently in a time sensitive environment.

Essential Functions

Specific Job Responsibilities

1. 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.

2. 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.

3. 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.

4. Responds to inquiries by regulatory and accreditation bodies.

5. Conducts root-cause analyses on known DOH/TJC standards and develops action plans to address all causes in collaboration with facility leadership.

6. Monitors implementation of all regulatory plans of correction, reporting variances or deviation from the plan.

7. 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.

8. 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.

9. 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.

10. 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.

11. May participate in leadership rounding to engage with caregivers and front line employees responsible for meeting standards.

12. 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. 13. Prepares Annual Evaluation of the seven Environment of Care Plans to present to the Safety Committee and Governing Board.

14. Develops, coordinates, facilitates and maintains CNMC disaster/emergency/EOC management plans; ensures all staff are competent in emergency/disaster management preparedness.

15. Develops, implements and coordinates facility-wide emergency trainings; prepares and delivers appropriate training to all staff of CNMC.

16. Coordinates and conducts drills in cooperation with the CNMC EOC and local officials as needed.

17. Maintains positive relationships with federal, state and local emergency response groups, including local fire, law enforcement, EMS providers and other emergency management groups.

18. Ensures effective and immediate communication with Senior Management during an emergency or disaster (i.e. impending storms requiring Senior Management to respond to events).

19. Keeps abreast of changes to laws and regulations that impact CNMC, utilizing best practices in emergency management and planning; attends meetings, conferences and workshops related to emergency/disaster management.

20. Serves on the Environment of Care (EOC) Committee; Assists in preparation of items for the meetings; Prepares the agenda; Acts as the chairperson in the absence of the chair for the meetings.

21. Maintains current Emergency/Disaster Preparedness/EOC and Life Safety policies in Policy Stat, revising as necessary.

22. Maintains Safety Data Sheets (SDS) in all required areas throughout the facility; ensures all SDS are up to date at all times, revising as needed.

23. Acts as and functions as the maintenance and security/plant ops department secretary by answering the department phone, assisting with coordination of duties and tasks, contacting vendors and contractors, typing memos and maintaining online/computer systems and programs for the department, etc.

24. Orders supplies to ensure efficiently functioning facilities department.

25. Reports all incidents, accidents, hazardous conditions or equipment to the Maintenance and Security Manager or Director, Facility Operations/Maintenance.

26. Inspects work areas and equipment frequently for safety, fire protection and prevention, etc.; Ensuring promoting a safe environment in all actions.

27. Ensure effective communication and delegation of duties, as needed, when absent from the facility.

28. Maintain privacy and confidentiality of records, conditions and other information relating to patients, employees and the facility.

Nonessential Functions Other Duties:

Performs all other duties and responsibilities as assigned in accordance with qualifications

Functional Demands:

Populations Served X Does not treat or care for patients. –¡ Neonate (60 years) Protected Health Information Type of Protected Information Accessed: –¡ Demographic –¡ Clinical –¡ Insurance –¡ Financial –¡ Complete Medical Record Bloodborne Pathogens Exposure While performing this job, occupational exposure is present for all employees Physical Requirements - Physical Dexterity and Effort: Rarely

EEOC Statement

Lake Cumberland Regional Hospital is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.