General Summary

Maintain thorough understanding of, and comply with, the most recent standards established by applicable accrediting Authorities Having Jurisdiction (AHJ) such as the Joint Commission (TJC), The Association for Assessment and Accreditation of Laboratory Animal Care (AAALAC), The College of American Pathologists (CAP), The American Association of Blood Banks (AABB), etc., as well as other applicable industry medical codes and standards governing the operation of a medical facility.

Essential Duties and Responsibilities

• Record and maintain documentation to validate compliance with these codes and standards.
• Remain abreast of any changes which impact facilities and ensure that all work supports any changes made by the AHJ.
• Prepare and submit an Accreditation Compliance and Documentation Plan for Government review and approval.
• Develop and submit an Environment of Care (EC) Policy and Procedures Manual addressing all training and record keeping for documentation of employee competency.
• Satisfy requirements of the EC Standards relating to utility systems and all other building systems (fire safety equipment, emergency power systems, medical gas and vacuum systems, HVAC, EMCS, etc.).
• Maintain management program that is used to identify and document utility problems, failures, and user errors that are or may be a threat to the patient care environment.
• Participate in activities of the medical treatment facility (MTF) that are designed to meet the requirements of TJC pertaining to Process Improvement (PI) programs (including PI monitors, data collection, report preparation, and presentation).
• Conduct quarterly in-process, line item reviews of program
• Other duties as assigned.

Knowledge, Experience and Skill Requirements

• Certified Healthcare Facility Manager (CHFM) Certification required
• Minimum of two (2) years’ experience with The Joint Commission compliance (maintenance and documentation, including all DMLSS work requests and all supporting testing/certification/verification requirement)
• Working knowledge of applicable related codes and standards such as NFPA, ADA, ABA, Unified Facilities Criteria, ASHRAE,
• Working knowledge of The Joint Commission Life Safety and Environment of Care
• standards, to include experience working with submitting and managing reports such as the Electronic Statement Of Conditions (e-SOC)

Work Environment

• Works in office areas as well as throughout the facility.
• Physical demands include intermittent sitting, standing, and walking, and occasional bending reaching and lifting.
• Limited exposure to elements such as heat, cold, noise, dust, dirt, chemicals, etc. but generally not to the point of being disagreeable.

This job description is subject to change by the employer as the needs of the employer and requirements of the job change.

We maintain a drug-free workplace and perform pre-employment substance abuse testing.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)