Compliance and Safety Specialist

The Compliance and Safety Specialist is responsible for implementing, maintaining, and coordinating workplace safety and regulatory compliance programs throughout the hospital. This position supports adherence to OSHA, DEA, and applicable state and federal regulations; conducts workplace hazard assessments; coordinates safety initiatives with clinical and facilities teams; and maintains required compliance documentation and reporting.

The role works collaboratively with hospital leadership and department managers to promote a safe working environment, identify potential risks, and support ongoing regulatory compliance.

Essential Job Functions

Facility Safety and Inspections

• Conduct monthly safety inspections throughout all hospital areas to identify, document, and address potential hazards.
• Verify that fire extinguishers are current and functional, eyewash stations are operational, emergency lighting is functioning, spill kits and first aid kits are adequately stocked, and chemical containers are properly labeled.
• Monitor compliance with fire inspection requirements and ensure corrective actions are documented and completed.
• Coordinate with the Facilities Manager regarding schedules and completion of required inspections and preventative maintenance, including alarms, sprinkler systems, HVAC, and equipment.
• Assist with the coordination and maintenance of emergency preparedness, evacuation, and disaster response plans.

OSHA and Regulatory Compliance

• Ensure required OSHA postings are current, accurate, and displayed in designated areas.
• Maintain the Safety Data Sheet (SDS) catalog and ensure chemical labeling and accessibility requirements are met.
• Conduct quarterly incident reviews to identify trends, assess potential risks, and recommend preventive measures.
• Communicate incident trends, findings, and recommendations to Human Resources and hospital leadership.
• Maintain documentation supporting compliance with applicable workplace safety regulations and requirements.

Safety Training and New Hire Orientation

• Develop and coordinate safety training programs in collaboration with the Training Team, ensuring employees receive required training before exposure to applicable workplace hazards and annually thereafter, as required.
• Conduct new hire safety orientation covering facility layout, emergency procedures, fire extinguisher locations, evacuation routes, and applicable hazard communication requirements.
• Maintain accurate records of training attendance, completion, and employee acknowledgments.

Waste Management and Sharps Compliance

• Oversee regulated medical waste and hazardous chemical waste programs, including sharps containers, biohazard bags, and chemotherapy waste disposal.
• Partner with the Purchasing Team to maintain adequate supplies of sharps containers and biohazard disposal materials.
• Ensure proper waste storage, handling, and safety protocols are followed.
• Coordinate with waste disposal vendors and maintain required manifests, disposal records, and proof of destruction documentation.

Clinical Safety Coordination

• Collaborate with clinical leadership to support staff awareness and compliance with hazardous drug handling protocols. Clinical protocols remain the responsibility of the appropriate clinical leadership.
• Monitor and document compliance with anesthetic gas handling, infectious disease prevention, and zoonotic disease management requirements.
• Escalate clinical safety concerns and identified deficiencies to the Director of Medical Staff or Chief Medical Officer (CMO), as appropriate.
• Ensure required radiology safety awareness training is completed and maintain documentation of training and compliance monitoring.
• Facilitate communication between clinical teams and the hospital safety program, ensuring incidents and safety concerns are appropriately reported and escalated.

DEA and Controlled Substance Compliance

• Collaborate with the Director of Operations on controlled substance inventory management, including ordering, receiving, inventory tracking, and reconciliation.
• Maintain accurate records of controlled substances received, distributed, administered, and otherwise removed from inventory.
• Maintain required Prescription Monitoring Program (PMP) reporting and documentation associated with prescriptions processed through Cubex, in accordance with applicable requirements.
• Identify, document, and promptly escalate discrepancies in controlled substance inventory.
• Maintain and renew Controlled Substance Ordering System (CSOS) certificates and administer the Cubex system.
• Train authorized personnel on appropriate controlled substance handling, documentation, and system usage.
• Support compliance with applicable DEA regulations governing the ordering, receiving, dispensing, administration, and recordkeeping of controlled substances.

Leadership Reporting and Documentation

• Promptly report safety concerns, resource deficiencies, regulatory compliance issues, workplace injuries, and other identified risks to the Director of Operations and appropriate hospital leadership.
• Maintain comprehensive and organized records of federal and state regulatory requirements, inspections, incidents, training, and compliance activities.
• Support internal reviews, audits, and regulatory inspections by ensuring required documentation is accurate, current, and accessible.

Qualifications

Required Qualifications

• Associate degree or an equivalent combination of education and relevant experience.
• Minimum of three (3) years of experience in workplace safety, regulatory compliance, healthcare or veterinary operations, or a related field.
• Working knowledge of OSHA standards and workplace safety requirements.
• Strong organizational, project management, and analytical skills.
• Experience working with data, reports, and spreadsheets.
• Ability to work independently, exercise sound judgment, and manage multiple priorities.
• Ability to read, interpret, and apply technical materials, regulations, and applicable laws.
• Excellent written and verbal communication skills.
• Proficiency in Microsoft Office Suite.
• Strong attention to detail and accuracy in recordkeeping and documentation.
• Professional demeanor and ability to communicate effectively with employees and leadership at all levels.

Preferred Qualifications

• OSHA 10-hour General Industry card or OSHA 30-hour certification.
• Familiarity with clinical procedures and veterinary medicine; Veterinary Technician experience is a plus.
• Experience with Cubex or similar controlled substance management systems.
• Experience delivering training, facilitating presentations, or educating employees on safety and compliance procedures.

Schedule: 

• Monday–Friday, with flexibility to adjust hours as needed to connect with overnight teams and support hospital-wide safety and compliance initiatives.

Physical Demands

The physical demands described below are representative of those required to perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

• Regularly required to sit, stand, walk, talk, see, and hear.
• Occasionally required to lift, push, or pull up to 25 pounds.
• Must be able to navigate all areas of the hospital facility to conduct inspections, assessments, and safety-related activities.