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Pharmacy Regulatory Compliance Specialist - ONC Pharmary - Days


Pharmacy Regulatory Compliance Specialist - ONC Pharmary - Days - Orlando Health Orlando Regional Medical Center (ORMC)

Position Summary:

Oversees and ensures compliance with required pharmacy inspection and documentation of emergency code carts / boxes and enter the results into Performance Improvement database as identified. Also oversees and ensures compliance with the Agency for Health Care Administration (AHCA), OSHA, CMS regulations and Orlando Health environment of care requirements.


  • High school diploma or equivalent required.


  • Must be currently registered with the Florida State Board of Pharmacy, renewed every two years.


  • Two (2) years pharmacy experience required.

Essential Functions:

  • Manages the site-specific Pharmacy Continuous Quality Improvement (CQI) program which includes the following: Investigating each event, entering and analyzing data from CQI sheets. Identifying and implementing action steps to prevent future errors. Facilitating and recording of CQI staff meetings.
  • With guidance by Orlando Health regulatory compliance personnel and the pharmacy manager/designee, participates in the evaluation of compliance with The Joint Commission National Patient Safety Goals and interacts with appropriate staff and management in the implementation of the Joint Commission National Patient Safety Goals involving medications and other medication safety- related regulatory requirements.
  • When appropriate, generates Incident Reports related to medication misadventures
  • Participates in data collection and evaluation to support corporate and/or site-specific operational and safety initiatives.
  • Coordinates with the Pharmacy Technology Specialist, Pharmacy Buyer and Controlled Substance Specialist to maintain and improve the safety and integrity of pharmacy dispensing processes.
  • Coordinates with Corporate Pharmacy Educator to ensure that pharmacy staff participates in appropriate in-services related to medication safety and participation by staff is properly documented.
  • Participates and serves on committees and task forces as appropriate to his/her duties as a Pharmacy Regulatory Compliance Specialist.
  • Develops and presents site-specific in-services to educate pharmacy and/or hospital staff.
  • Evaluates and documents Pharmacy Technician Annual Clinical Review
  • Evaluates and oversees compliance with U.S.P 797 regulations which includes the following:
  • Appropriate determination and documentation of education and competency of I.V. room personnel.
  • Appropriate environmental monitoring and cleaning of the I.V. room.
  • Appropriate monitoring of I.V. room workflow and processes to ensure U.S.P. 797 compliance.
  • Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
  • Maintains compliance with all Orlando Health policies and procedures.


  • Two years of experience.

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