Position Summary:
The Facilities & Safety Compliance Coordinator is responsible for coordinating and maintaining the physical environment, life safety, and regulatory compliance across all CTGI MSO-operated endoscopy centers. This is an individual contributor role focused on keeping each center inspection-ready, operationally safe, and in continuous compliance with CMS, AAAHC, OSHA, NFPA, and applicable state and local standards. The Coordinator is expected to be a hands-on, organized self-starter who can manage compliance calendars, coordinate vendor services, conduct site visits, and maintain meticulous documentation without direct supervisory authority over center-level staff. This role reports directly to the CEO and interfaces regularly with center administrators and clinical leadership.
Essential Functions & Key Responsibilities
Regulatory Compliance & Survey Readiness
- Track and maintain compliance with CMS Conditions for Coverage (42 CFR Part 416), AAAHC accreditation standards, and state health department facility regulations across all centers.
- Own the life-safety compliance book for each site — including maintenance records, inspection logs, and corrective action documentation — and ensure it is current and audit-ready at all times.
- Coordinate and participate in AAAHC, CMS, and state survey visits; prepare centers through mock survey walkthroughs and pre-inspection checklists.
- Issue corrective action plans (CAPs) for any identified deficiencies and track resolution to completion.
- Monitor compliance with NFPA Life Safety Code requirements applicable to ambulatory occupancy classification.sential Functions & Key Responsibilities
Life Safety & Environment of Care
- Coordinate and manage the documents surrounding the testing and maintenance of all lifesafety systems across each center, including fire alarm and suppression systems, emergency General Business egress lighting, exit signs, fire extinguishers, fire dampers, fire doors, backup generators, and medical gas systems.
- Ensure regular generator transfer tests, fire safety inspections, and fire damper inspections are scheduled, completed, and documented per NFPA and CMS requirements.
- Monitor HVAC system maintenance to support compliance with ASHRAE 170 standards for procedure rooms, scope reprocessing areas, and sterilization rooms. Coordinate High level disinfection equipment maintenance documentation, including biological indicator logs, chemical indicator records, and load tracking per SGNA and best practice
- Conduct monthly Environment of Care Rounds, document findings, make corrections, and coordinate repairs with vendors,
Facilities Coordination & Vendor Management
- Serve as the MSO-level point of contact for facilities vendors, including HVAC contractors, fire safety companies, biomedical equipment servicers, janitorial services, and waste management vendors.
- Coordinate vendor scheduling, track service completion, and ensure vendor documentation (inspection reports, certificates of completion) is filed in each center's compliance records.
- Conduct regular site visits at each center; document observations and follow up on any open maintenance or compliance items with the center administrator.
- Maintain a work order tracking log and escalate unresolved issues to center administrators and the CEO as needed.
- Support capital planning by flagging aging equipment, deferred maintenance items, and infrastructure concerns to the CEO.
Emergency Preparedness
- Maintain and update CMS-compliant emergency preparedness plans for all centers, including fire evacuation, hazardous material response, power outage, and disaster recovery protocols.
- Schedule and coordinate annual emergency preparedness drills at each center; document participation and outcomes.
- Serve as a coordination point for emergency events affecting center operations, working with center administrators and the CEO.
- Schedule, prepare, coordinate, and document quarterly fire drills
Infection Control Infrastructure Support
- Coordinate with clinical leadership to ensure physical plant operations support the center's infection prevention and control program.
- Track environmental conditions in procedure rooms, scope reprocessing areas, and sterilization rooms (airflow, pressure differentials) and flag out-of-spec readings for corrective action.
- Ensure regulated medical waste and hazardous material disposal practices comply with applicable regulations at each site.
Documentation, Training & Reporting
- Maintain a centralized, organized compliance documentation repository for all centers, accessible for rapid retrieval during surveys or audits.
- Assist in developing and updating MSO-wide facilities and safety policies and standard operating procedures.
- Coordinate safety training for center staff on fire safety, OSHA standards, emergency procedures, and environment-of-care topics.
- Track and report key facilities and safety metrics to the CEO on a defined monthly cadence.
Qualifications
Education
- Associate's or Bachelor's degree in Facilities Management, Healthcare Administration, Environmental Health & Safety, or a related field preferred; equivalent work experience will be considered.
Experience
- Minimum 3 years of experience in facilities coordination, safety compliance, or operations in a healthcare setting.
- Experience in an ambulatory surgery center (ASC), endoscopy center, or multi-site outpatient healthcare environment strongly preferred.
- Familiarity with CMS, AAAHC, or Joint Commission accreditation requirements preferred.
- Experience coordinating multiple vendors and maintaining compliance documentation across multiple locations a strong plus.
Certifications (Preferred, Not Required)
- OSHA 10-Hour or 30-Hour General Industry or Healthcare certification
- NFPA Life Safety Code training
- AAAHC accreditation preparation coursework
- Certified Healthcare Facility Manager (CHFM)
Pay: $53,010.96 - $75,841.16 per year
Benefits:
- 401(k)
- Flexible spending account
- Health insurance
- Health savings account
- Paid time off
- Retirement plan
- Vision insurance
Experience:
- Facilities management: 1 year (Preferred)
Ability to Commute:
- Rocky Hill, CT 06067 (Required)
Willingness to travel:
Work Location: In person
