Job Purpose & Position Overview
The Safety and Security Manager support Winnebago Comprehensive Healthcare System (WCHS) in maintaining compliance with CMS Conditions of Participation (CoPs), including §485.623 (Physical Environment) and §485.625 (Emergency Preparedness), by ensuring a safe, functional, and secure environment for patients, staff, and visitors. This role serves as the designated Safety and Security Manager for hospital operations, and implements the Environment of Care (EOC), Security, and Hazardous Materials/Waste programs.
Specific Job Duties:
- Ensure compliance with CMS CoPs §485.623 (Physical Environment), including maintenance of a safe, sanitary, and functional environment.
- Support Emergency Preparedness program compliance under §485.625, including participation in staff education, drills, exercises, and HIMT response.
- Implement and monitor EOC management plans aligned with CMS and Life Safety Code requirements (§485.623).
- Support compliance with 42 CFR§§485.608, 485.635, and 485.641 through oversight of Workplace Violence prevention activities, safety initiatives, incident review, and performance improvement efforts.
- Direct hazardous materials response program, ensuring safe handling of spills and emergencies in accordance with OSHA and EPA requirements.
- Manage hazardous waste storage, handling, and disposal consistent with federal and state regulations supporting patient and staff safety.
- Conduct environmental rounds and correct deficiencies to ensure safety and functionality.
- Participate in incident investigations and root cause analyses tied to patient safety and quality improvement (§482.21 Quality Assessment and Performance Improvement).
- Coordinate ILSM and ICRA processes to maintain life safety compliance during construction per §482.41(b).
- Collaborate with Infection Control per §482.42 to minimize environmental risks for healthcare-associated infections.
- Manage workplace safety programs to reduce staff injury consistent with OSHA and CMS expectations for safe staffing environments.
- Conduct fire drills and evaluate performance in compliance with Life Safety Code requirements incorporated under §482.41.
- Serve as primary contact during CMS and accreditation surveys.
- Leads working groups and committees, and or coordinates with other hospital staff to reduce risk/injury to patients, visitors, and staff.
Program Oversight & Supervision
- Oversee Safety, Security, Workplace Violence, Threat Assessment, and Hazardous Materials/Waste programs in alignment with regulatory requirements.
- Ensure programs meet CMS CoPs and regulatory compliance standards (§485.623).
- Report risks, deficiencies, and performance improvement actions to leadership and governing body (§485.627).
- Will serve as designated Hospital Security Manager directly overseeing the Security Department and all associated staff.
- Will serve as designated Hospital Safety Officer and directly implement Environment of Care plans to support the overall Safety program, in coordination with Infection Control, Employee Health, and hospital leadership.
- Workplace Violence Committee Leadership: Chairs the Workplace Violence Prevention Committee; leads meetings, follow-up, and action planning. Works with interdisciplinary leaders to review risks, incidents, and trends, and implement improvements aligned with CAH quality requirements to support staff safety (§485.641).
- De-escalation Training Program Administration: Oversees de-escalation training to ensure staff competency through initial and ongoing education. Monitors compliance, evaluates effectiveness, and updates training based on risk and performance findings (§485.625, §485.623).
- Staff Duress Program Administration: Manages staff duress and emergency communication systems. Ensure proper implementation, testing, training, and continuous improvement while analyzing data to strengthen response and safety (§485.623).
- Fall Prevention Committee Co-Leadership: Co-chairs the Fall Prevention Committee and supports the overall program. Reviews fall data, identifies causes, and implements corrective actions to reduce risk and improve safety outcomes (§485.641, §485.640).
Training & Education of Staff
- Develop and deliver safety and security training programs.
- Provide guidance on regulatory standards and occupational safety practices.
- Support ongoing EOC regulatory readiness education.
Policy & Procedure Support
- Interpret and educate staff on EOC, Life Safety, and Emergency Management policies.
- Research and integrate regulatory requirements into policies and procedures.
- Provide training on accreditation standards and compliance expectations.
Qualifications, Skills, and Knowledge:
- Bachelor’s degree in safety management or related field (or equivalent experience); master’s preferred.
- Must possess or be able to obtain relevant IAHSS certification (Basic, Advanced, Supervisory, and Safety).
- Minimum 3 years of experience in safety/risk management, security, or emergency management.
- Minimum 3 years of supervisory experience required; Healthcare experience preferred.
- Experience in developing policies and procedures required.
- Knowledge of healthcare facilities management and regulatory standards (NFPA, TJC, CMS, OSHA).
- FEMA ICS 100/200/300/400/700 preferred.
- Proficiency with Microsoft Office and security management applications.
- Strong reading, writing, analytical, and problem-solving skills.
- Effective communication, interpersonal, and conflict resolution skills.
- Strong ability to work independently with minimal supervision.
- Must be able to read, write, and understand regulatory materials and interpret drawings.
- Must have valid driver’s license and be insurable under the Winnebago Tribe of Nebraska’s current policy.
Physical Requirements
- Ability to perform office and field work, including lifting to 50 lbs.
- Frequent walking, standing, climbing, and inspection work in clinical and construction environments.
- Extended use of computers and standard office equipment.
Cognitive Requirements:
- Ability to read, write, and perform basic calculations.
- Ability to communicate effectively, verbally and in writing.
- Ability to think critically, demonstrate good business judgment, and make decisions that align with the organization’s mission, vision, and values.
- Ability to work independently with minimal supervision while managing multiple priorities.
Language Requirements:
- Ability to read, write, and speak English fluently.
- Ability to use professional verbal and written communication skills consistently and effectively.
Certificates, Licenses & Registrations:
- All applicants will comply with 45 CFR 1301, Subpart D, Section 1301.31, C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and to comply with PL 101-630 and PL 101-637 regarding criminal records check.
Please note the position description duties, responsibilities, and activities may change at any time with or without notice.
WCHS is an equal opportunity employer.
All applicants must comply with 45 CFR 1301, Subpart D, Section 1301.31 C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and comply with PL 101-630 and PL 101-637 regarding criminal records check. As provided by Federal Law, all qualified Native American and Veteran applicants shall receive preference over Non-Native American applicants. In the absence of qualified Native American applicants, consideration will be given to all other applicants without regard to race, color, religion, gender, gender orientation/identity, national origin, age, marital status, veteran status, genetic information, disability or any other reason prohibited by law in provision of employment opportunities and benefits. WCHS participates in E-Verify.
