Strength Through Diversity
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Planning, Design and Construction - Req. 2421038
Job Title: Senior Director, Real Estate Compliance and Fire Safety
Roles & Responsibilities:
- Takes a leadership role in the preparation for upcoming surveys (i.e, JC, OSHA, EPA, DEC, DEP, internal etc), identifying areas for improvements and for monitoring improvements.
- Coordinates Joint Commission (JC) / CMS readiness audits in the areas of EOC, Life Safety and Emergency Management.
- Prepares regulatory responses to JC and CMS in Life Safety as well as provide assistance in other areas of JC/CMS response and follow-ups.
- Tracks and reports timely implementation of Plan of Corrections
- Works directly with agency inspectors or surveyors as needed and as directed by the VP of Real Estate and Sr Dir EH&S.
- Works with all Environment of Care leaders to ensure documentation is up to date.
- Develops EC Committee agenda to meet established or newly adopted requirements; maintains fully comprehensive minutes, and follows up on actions to meet all requirements.
- Coordinates and reviews EOC Management Plans including core plan construction, goals and objectives, performance monitoring and performance improvement indicators as well as annual assessment reports.
- Provides semi-annual EOC report to the Quality Assurance and Performance Improvement committee.
- Collects, reviews, and analyzes regulatory data from internal and external sources to maintain Environment of Care and Life Safety programs current.
- Maintains effective communication with System departments and services to ensure compliance with policies and procedures as they impact on Environmental Safety functions. Interprets codes, laws, etc. and provides guidance to departments as necessary.
- Keeps abreast of Real Estate plan/developments and regulatory agency requirements. Compiles data and prepares reports to government agencies, management, and appropriate others as required.
- Takes a leadership role in construction-related safety. Ensures there are policies, procedures, and resources to support the Real Estate’s construction efforts to include the effectiveness of the penetration permits program, conducting random pre and post inspections, attending appropriate project meetings, giving design guidance, and eventual granting of approval relative to Pre-Construction Risk Assessments (PCRA). Participates in the Infection Control Risk Assessment (ICRA) aspects related to construction. Works with Fire Safety in the preparation of the PCRA. Conduct independent safety rounds of construction sites.
- Reviews appropriate fire safety training programs and fire drills. Designs and distributes instructional or informational materials.
- Partners with the System’s training centers and other training offices and areas of the Hospital to devise the best, most comprehensive training programs that will meet regulatory requirements and enhance the safety of patients, visitors and staff.
- Responsible for the management of hazardous materials and wastes in accordance with established city, state or federal regulations and procedures.
- Consults with Laboratory staff and appropriate others to ensure staff use of PPE, the safe storage, transportation, and disposal of chemical wastes. Conducts random audits to verify staffs adhere to PPE use requirements in the work area.
- Oversees hazardous and regulated medical waste disposal vendor performance and monitors results regarding proper tracking of waste (from “cradle to grave”).
- Prepares and maintains budget for waste disposal program.
- Reviews and audits inspection, testing and preventive maintenance activities of fire protection and safety equipment. Conducts internal audits of the Engineering department’s records for inspection, testing and maintenance of fire alarm and suppression systems. Conducts internal audits and provides guidance to other hospital departments. Tracks corrective actions to completion.
- Initiates purchase of new safety equipment including equipment for industrial hygiene (IAQ monitoring devices, multi-gas meters, etc.), hazardous material spill control, fire extinguishers, fire/smoke dampers and/or orders repairs as necessary.
- Designs and/or revises forms and administrative systems for efficient and accurate reporting of safety related information.
- Provide information to Regulatory Compliance during JC’s mid-cycle review documentation (EC and LS standards).
- Coordinates EOC tours and risk assessments, monitors for accuracy and ensures deficiencies are followed up to closure, conducts data analysis and reports trending analysis
- Conducts analysis of all reportable accidents/incidents for statistical evaluation and provides updated reports for EOC and QPIC
- Participates in various task forces and meetings related to Safety activities.
- Maintains knowledge of field conditions.
- Reviews all EOC policies as needed
- Updates core competencies safety section manuals for MSBI and Nursing staff
- Develop processes to train nursing staff on EOC, Life Safety and Emergency Management
- Maintains chemical inventory, and complete NYC DEP Community Right to Know documents for MSBI, PACC, and BIB, at least annually (due every March 1st)
- Conducts New Associate Orientation
- Provide technical evaluation for Fire Safety, Life Safety, OSHA, and EPA regulations. This includes attending seminars and training on pertinent topics, and regulations. Disseminate information to pertinent staff on new regulations and interpretations.
- Works with Engineering, Materials Management, EVS and other departments to conduct OSHA compliant training programs
- Review of construction and renovation projects for compliance with LSC.
- IF applicable, conduct vapor/gas/other chemical occupational exposure evaluations and tests as needed and or required by code
- IF applicable, conducts/coordinates inspections of hazardous waste satellite and main accumulation areas to check on facility compliance.
- Manage and conduct trainings to improve staff knowledge on OSHA, JC (EOC/LS/EM), and EPA requirements.
- Attend construction meetings, as needed.
- Attend all other relevant meetings, including Emergency Management, Infection Control, Radiation Safety, Quality and Performance Improvement Committee.
- Provides technical guidance or comments on dealing with code compliance issues.
- Performs all duties inherent to Director’s role. Participates in hiring, training, evaluation, and termination of assigned staff according to Hospital policies and procedures.
- Performs other special projects and duties as assigned.
- Develops, modifies, and maintains Environmental Safety standards to support approved organizational goals and comply with outside agency regulations.
- Coordinates and regulates departmental Safety Programs to ensure effectiveness.
- Develops/revises programs and recommends procedural changes as necessary.
- Conducts and oversees inspections and industrial hygiene programs (including environmental sampling sessions) to ensure accident prevention, fire protection, and safety from hazards. Initiates corrective actions as require
- Manages and oversees department staff, provides work direction, and conducts on-the-job training to ensure the department has a course-trained knowledge base in the functional areas of Joint Commission Environment of Care, Life Safety and Emergency Management as well as OSHA, EPA, and NYS DOH rules and regulations among others.
- Completes staff performance evaluations and takes appropriate personnel actions.
- Monitors activities of staff to ensure effective completion of projects and assignments.
- Interprets and implements Hospital personnel and department policies and procedures.
- Prepares annual department and capital budget for approval.
- Monitors and reconciles expenditure of funds.
Strength Through Diversity
The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.
We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care.
Explore more about this opportunity and how you can help us write a new chapter in our story!
Who We Are
Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation.