Regulatory Specialist Emergency Management
Holy Cross

Fort Lauderdale, Florida

Posted in Medical and Nursing

This job has expired.

Job Info

Employment Type:
Full time


Role and Responsibilities:

Maintains continuous survey readiness through compliance with regulations from a number of regulatory agencies, including The Joint Commission (TJC), the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), the National Fire Protection Association (NFPA), and identified industry best management practices.

Maintains current knowledge of all applicable codes, regulations, standards and accreditation requirements for area of responsibility with special attention to Life Safety, Environment of Care, and Emergency Management

Serves as Safety Officer with direct oversight of Emergency Management Program

Serves as the primary fire / life safety code Subject Matter Expert for Holy Cross Health.Validates regulatory findings before investing in changes or corrective actions. Collaborates with local and State fire officials, Facilities Managers and Construction / Real Estate team members to evaluate new codes / code changes that will impact Holy Cross Health facilities.

Coordinates and monitors Fire and Life Safety program elements in compliance with Federal, State and Local regulations.

Manages the Interim Life Safety Management (ILSM) program and all pertinent documentation for all Holy Cross Health facilities. Conducts Pre-Construction Risk Assessments to evaluate for life safety deficiencies during construction and renovation projects. Collaborates with contractors and other team members in assessment, mitigation development, and education related to Life Safety risk and oversight of implementation of Interim Life Safety Measures (ILSM).

Participates in the testing, inspection and repair activities of the Life Safety Systems with facilities/vendors and serves as the Fire/Life Safety evaluator for the inspection process.

Coordinates and conducts all Fire drills across the system. Fire drill process, including development of scenarios, scheduling and implementation of drills, to include proper documentation of the exercises. Monitors and reports compliance to operational leaders.

Prepares and presents effective employee training on proper fire / life safety response procedures.

Assists Facilities/Construction/Vendor personnel with the evaluation of Life Safety drawings to assure accuracy and provides recommendations for revision frequency.

Maintain Joint Commission required Statement of Conditions

Participate in Life Safety and Environment of Care regulatory survey reviews with The Joint Commission, State/City Fire Marshals, State/CMS surveyors and/or any other regulatory body.

Coordinates and monitors progress of all Evidence of Standards Compliance activities related to Life Safety and/or Emergency Management in partnership with the Joint Commission Compliance Manager.

Direct oversight of required Emergency Management Plan, Fire Safety Management Plan, and Workplace Violence Program.

Acts as Chair for the Emergency Management Committee and Preparedness Program with ultimate responsibilities as follows:

  • Maintenance of the institution's Comprehensive Emergency Management Plan (CEMP), Emergency Operation Plan (EOP), and all related preparedness policies, procedures and guidelines.
  • Conduct an annual hazard vulnerability assessment (HVA)/ risk analysis to determine the facility's risk for natural (e.g., hurricanes, floods, earthquakes), technological (e.g., nuclear power plant emergencies or hazardous materials spills), human-caused (e.g., active shooter or hostage situations), and other disasters.
  • Develop and maintain emergency plans and procedures for disasters identified in the HVA/ risk analysis.
  • Know when to activate the facility's emergency operations plan and hospital command center.
  • Know the organization's alert and notification system and procedures, and ensure appropriate staff is educated on this as well.
  • Provide warnings and emergency data to the organization, and operations and technical support to leadership before, during, and after emergencies that affect it
  • Manage disaster response or crisis management activities for the facility. Ensure availability of staff 24/7 to respond to disaster or potential disaster situations.
  • Coordinate the collection of organization-wide regulatory required information including, but not limited to, hazardous materials inventory, departmental hazard surveillance, and disaster supply inventories.
  • Assist Directors/Managers in management, development, and expensing of department specific emergency preparedness plans.
  • Ensures that the EOP and relevant preparedness materials are reported to and reviewed annually by Emergency Preparedness leadership, the Environment of Care and Safety Committee and other appropriate leadership.
  • Participates in local, regional and state Emergency Preparedness committees, coalitions and activities as directed (e.g., Region 6 Healthcare Coalition).
  • Develops and prepares documentation to fulfill requirements related to education, exercises, equipment and grants.
  • Organizes, coordinates and implements periodic preparedness exercises and drills in line with regulatory requirements. Uses FEMA guidelines, templates and tools to plan, conduct, evaluate and document drills and exercises for process improvement.
  • Oversees preparation and facilitation of the HCH Emergency Preparedness/Disaster Committee.
  • Monitors local, regional, state and federal Emergency Preparedness literature, trends, events and activities to support continuous professional development and program improvement.
  • Presents periodic Emergency Preparedness reports to the Emergency Preparedness Committee, the Environment of Care (EOC) Safety Committee, hospital leadership and other forums, as required.
  • Develops and conducts emergency preparedness education, awareness, and training for HCH associates.
  • Coordinates the activities of the HCH Emergency Response Team (HERT), including member recruitment, education, exercises, equipment management and policies and procedures.
  • Responsible for inventory, maintenance, training, operation, order and requisitions of all emergency preparedness equipment including DECON, HERT, Evacuation, and communications equipment.

Collects deficiency information for Life Safety and Emergency Management and disseminate summaries of countermeasures and results to the Environment of Care and Safety (EOC) committee; as well as has standing time allocated to provide specific examples and mitigation plans via system wide Joint Commission Leadership Meetings.

Performs all other duties considered applicable to their role and within scope of practice as assigned.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

This job has expired.

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