Employee Health & Regulatory Compliance Nurse

Description

Job Summary:

The Employee Health & Regulatory Compliance Nurse is responsible for coordinating and maintaining the hospital’s Employee Health Program while providing regulatory compliance support which may include clinical, regulatory, quality, infection prevention, patient safety and risk management support within the Quality Department.

This position reports directly to the Director of Regulatory Compliance & Patient Safety, who also provides oversight of the hospital’s Infection Prevention and Control Program. 

Employee Health is a primary area of responsibility for this position. In addition, the RN assists the Director of Regulatory Compliance and Patient Safety, Quality Manager and Vice President of Quality with assigned activities related to regulatory compliance, infection prevention, performance improvement, quality assurance and risk management.

Employee Health Program

The Employee Health & Regulatory Nurse serves as the primary coordinator of the hospital’s Employee Health Program. The RN is responsible for the day-to-day administration, tracking, follow-up, documentation, surveillance and coordination of Employee Health activities within the authorities delegated by hospital leadership and established policies. The Director of Regulatory Compliance and Patient Safety provides supervisory oversight of the Employee Health Program and the RN responsible for its operation. 

Infection Control Program

Because the Director of Regulatory Compliance and Patient Safety oversees Infection Prevention, the Employee Health and Regulatory Compliance Nurse also serves as a key clinical support resource for the Infection Prevention and Control Program.

The RN may assist with:

• Infection Surveillance and data collection
• Healthcare-associated infection monitoring
• Hand-hygiene surveillance
• Isolation and PPE audits
• Infection-prevention rounds
• Communicable disease investigations
• Employee and patient exposure investigations
• Employee immunization and infectious disease surveillance
• Staff education
• Infection-prevention audits
• Corrective-action monitoring
• Infection Prevention committee activities
• Regulatory reporting preparation, as assigned

The Director of Regulatory Compliance and Patient Safety retains responsibility for oversight of the Infection Prevention and Control Program. The structure of this position is intended to ensure that Employee Health responsibilities remain adequately supported while allowing the RN to function as a flexible clinical resource across regulatory compliance, infection prevention, quality and risk management.

Essential Duties and Responsibilities:

• Coordinate pre-employment and ongoing employee health requirements in collaboration with Human Resources
• Maintain confidential employee health records in accordance with applicable requirements and hospital policy
• Coordinate required employee health screenings and surveillance
• Track employee immunization and immunity documentation
• Coordinate Tuberculosis screening and surveillance
• Coordinate employee Influenza and other applicable vaccination programs
• Monitor compliance with employee health requirements and communicate deficiencies to appropriate individuals
• Coordinate occupational exposure evaluation and follow-up, including blood and body-fluid exposures and needlestick/sharps injuries.
• Facilitate appropriate post-exposure testing, treatment, documentation, counseling and follow-up according to hospital policy
• Assist with employee work-related injury and illness processes in collaboration with Human Resources and other designated personnel
• Coordinate employee return-to-work processes within established hospital policies and applicable provider recommendations
• Assist with respiratory protection program activities, including medical clearance and fit-testing coordination
• Provide employee education related to occupational health infection prevention, exposures and workplace safety
• Monitor Employee Health Program data and identify trends or opportunities for improvement
• Maintain Employee Health policies, procedures, forms, logs and other program documentation
• Assist leadership with evaluation and implementation of employee-health requirements
• Regulatory/Survey Readiness: ongoing readiness activities, participates in tracers, conducts assigned audits and rounds to evaluate compliance with hospital policies and regulatory requirements, assists departments in identifying and correcting compliance deficiencies, assists with tracking corrective action plans and following up on assigned items, participates in policy and procedure review and revision, assists with maintaining documentation, supports staff education
• Infection Prevention Support: assists with infection surveillance and data collection, conducts hand-hygiene observations and other infection prevention audits, performs infection prevention rounds, monitors compliance with isolation precautions and appropriate PPE use, assists with investigation and follow-up of potential healthcare-acquired infections, assists with communicable-disease investigations, supports employee and patient vaccination initiatives, assists with infection-prevention education, collects/organizes and reports infection prevention data as assigned, assists with implementation and monitoring of infection-prevention corrective action
• Quality and Performance Improvement: performs assigned medical-record reviews and quality audits, collects/abstracts/validates and organizes quality data, assists with preparation of quality reports and dashboards, tracks quality indicators and identifies trends for leadership review, assists with performance-improvement initiatives, assists departments with development and monitoring of performance improvement plans, tracks action items and monitors completion of assigned corrective actions, assists with preparation of material for committees as appropriate, assists with staff education regarding quality and performance-improvement initiatives
• Risk Management and Patient Safety Support: assists with review and follow-up of incident and event reports, collects documentation and information necessary for risk investigations, assists with identification and trending of organizational risk concerns, participates in risk-reduction initiatives, assists with implementation and monitoring of corrective actions resulting from identified risks, supports investigations involving patient or visitor events, maintains confidentiality of risk management information (all duties as assigned)
• Education: provides employee education related to employee health, infection prevention, occupational exposures, patient safety and assigned quality initiatives, assists with orientation of new employees regarding applicable Employee Health and Infection Control requirements, develops educational materials as needed, communicates changes in policies, procedures or requirements to appropriate staff, serves as an accessible resource for employees and department leaders within the scope of the position

Professional Requirements:

• Demonstrate ability to practically apply basic quality principles
• Ability to pass specific competencies for this position
• Ability to work under pressure with tight time constraints
• Human relations and organizational skills
• Completes and maintains all required education and/or training requirements.
• Comply with HIPAA regulations and always maintain patient confidentiality.
• Follow and maintain all lawful safety, health requirements, and regulations, and follow protocols for required protective equipment (PPE).
• Promptly report safety issues, job-related injury, or illness, near misses, etc. in SafetyZone.
• Follow Hillsboro Health Standards of Behavior.

Requirements

Education and/or Experience:

• Graduate of accredited nursing school
• Three years of clinical nursing experience preferred

Certificates and Licenses:

• Maintain current Illinois RN Licensure
• Associate degree in nursing required
• Bachelor’s degree in nursing preferred
• Basic Life Support (BLS) required or willing to obtain within 30 days of hire.

Physical Demands:

Physical demands of the position, including vision, hearing, repetitive motion, and environment are required. A separate document will be provided upon hire, during annual evaluation process, and upon request. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.

CORPORATE COMPLIANCE

Receives training and/or attends necessary meetings to meet the criteria as outlined in Hillsboro Health’s Corporate Compliance Plan and Code of Conduct. Understands the responsibilities related to compliance and knows whether to contact the Corporate Compliance Officer should there be any instance of question or concern regarding fraud and/or abuse.