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Compliance Specialist - Joint Commission - Balboa Naval Medical Hospital
San Diego , California
October 19, 2017
With codes and standards changing, the TJC Management Support Analyst will remain abreast of any changes which impact NMCSD facilities, and will ensure that all work supports any changes made by the AHJ. The TJC Management Support Analyst is responsible to be compliant with the current codes and standards of The Joint Commission during the life of this contract.

NMCSD has established and maintains a Building Maintenance Program (BMP) in accordance with TJC guidelines. The TJC Management Support Analyst EC Policy and Procedures Manual will address Johnson Controls policies and procedures required to perform all necessary maintenance and inspections in accordance with the BMP, including documentation requirements. The BMP includes inspecting and maintaining Fire Doors, Smoke Doors, Fire Barriers, Smoke Barriers, Corridor Doors and Walls, and Keeping Means of Egress Free and Clear, Means of Egress Illumination; and Kitchen Hood Cleaning.

Balboa Naval Medical Center (military experience not required)
Benefits: Eligible for benefits on first day of employment
Vacation: Eligible for 3 weeks of paid vacation per calendar year

1. Prepare and submit a TJC Accreditation Compliance and Documentation Plan for Government review and approval. The plan will, at a minimum, include the process and procedures that will be used to gather and display required documentation, the process to show objective evidence that all work is in compliance with each applicable AHJ's accreditation standards, for each element of performance, and will include specific requirements for each AHJ's compliance.

2. Record and maintain documentation to validate compliance with these codes and standards. This documentation will be available for review at any time by Government or third-party inspectors, including accreditation survey teams.

3. Will conduct an initial review of the NMCSD Environment of Care (EC) and Life Safety (LS) Policy and Procedures Manuals after task order award to determine level of compliance with TJC requirements.

4. Identifies all potential anomalies and deficiencies and prepares recommendations to resolve the discovered issues. Reviews all findings with the Facilities Management staff to determine a plan of action and milestones to enable the resolution of issues. Assists the Facilities Management staff in resolving issues and making necessary updates to above noted policy and procedures manuals. Will repeat the review and update process at least annually.

5. Monitors the requirements of the EC and LS Standards relating to all related building systems which the Modernization Project Contractors may be impacting or for which the O&M Contractor is responsible for maintenance (fire safety equipment, emergency power systems, medical gas and vacuum systems, HVAC, EMCS, etc.).

6. Reports any issues that may affect compliance with EC or LS Standards and assists in the resolution of those issues.

7. Will not be responsible for, but will participate in and contribute to other standards and elements of performance (EP) such as standards to manage, identify and respond to risks in the environment.

8. Will need to be prepared for an unannounced survey at any time, and will need to have plans and documents in place at all times.

9. Assists in the preparation and presentation of the Annual TJC briefing for the facility staff, focused on applicable updates and changes to TJC standards and practices

10. Assists in the preparation and presentation of the Annual review of Life Safety and/or other TJC required plans by Johnson Controls personnel qualified in the area.

11. Assists in conducting or conduct building tours periodically as required to confirm current building conditions, identify any related facility issues and review and recommend updates to the Statement of Condition (SOC) report.

12. Conducts quarterly in-process, line item reviews of this program with FMD

13. Type and distribute minutes of those meetings within 30 calendar days of the meeting.

14. For any items related to the O&M Contractors, the TJC Management Support Analyst will take action to ensure proper resolution of the discrepancies identified in the line item review.

15. Provides input to NMCSD's TJC Management Plans to include, but not be limited to, Environment of Care (EC), Life Safety (LS), Emergency Management (EM) and any other NMCSD Management Plans impacted by Johnson Controls operations, policies, and procedures. Prepares separate Johnson Controls management plans as determined by NMCSD. Draft input will be submitted to the COR concurrent with Johnson Controls Facility Operations & Maintenance Plan (FOMP) submission.

16. Provides input and assistance required to maintain NMCSD's Statement of Conditions and to initiate and maintain NMCSD Plans for Improvement.

17. Maintains hardcopy equipment maintenance documentation to comply with all Joint Commission facility inspection requirements. This information will be available immediately upon request from the CO or COR/designated representative.

18. Maintains and submits records/documentation to support NMCSD in maintaining Joint Commission accreditation.

19. Required Organization of TJC EOC EP Data that identifies the current organization of the NMCSD binders that retain Elements of Performance data. Reviews the NMCSD binders every 90 calendar days to ensure that NMCSD's TJC Element of Performance binders are ready and available for a TJC-related review.

Division: JCFS (Johnson Controls Federal Systems)

1. Master's Degree in a related field with a minimum of two (2) years of related
and documentable experience, or Bachelor's Degree in a related field with a minimum of two (3) years of related and documentable experience. Experience shall be current within the last five (5) years.
2. Thorough understanding of the most recent standards established by applicable accrediting Authorities Having Jurisdiction (AHJ) such as the Joint Commission (TJC) as well as other applicable industry medical codes and standards governing the operation of a medical facility such as those published by the National Fire Protection Association (NFPA), the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE), and the American National Standards Institute (ANSI).

3. Experience working with The Joint Commission Accreditation process

4. Experience with one or more Joint Commission surveys

5. Experience working with Environment of Care (EC), Life Safety (LS), Emergency Management (EM) and other maintenance management standards.

6. Experience working in a hospital/healthcare environment

7. U.S. citizenship required

8. The ability to obtain and maintain a DoD Secret security clearance required. (This involves a background/character, criminal history, employment, and credit check.)
9. Knowledge of the ESOP system preferred.
10. American Society for Healthcare Engineering (ASHE) preferred
11. Certified Healthcare Facility Manager (CHFM) certification preferred.

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