DIRECTOR OF LIFE SAFETY COMPLIANCE
About The Position
The Director of Life Safety Compliance provides specialized, project-based leadership in healthcare regulatory and Life Safety compliance. The primary responsibility of this role is to conduct comprehensive Life Safety assessments, accreditation mock surveys, field verification surveys, ligature risk assessments, and other consulting services related to physical environment regulatory requirements. This role is designed for a highly experienced healthcare compliance professional with deep expertise in Life Safety Code interpretation, survey readiness, and regulatory gap mitigation. The PRN Director will assess risk, identify deficiencies, and deliver structured corrective action strategies to ensure healthcare organizations maintain compliance with federal, state, and accrediting body standards.
Requirements
- Bachelor’s degree in Engineering, Healthcare Administration, Safety, or related field (or equivalent experience).
- Minimum 7–10 years of healthcare Life Safety or regulatory compliance experience.
- Extensive working knowledge of: NFPA 101 (Life Safety Code) NFPA 99 CMS Conditions of Participation The Joint Commission standards
- Demonstrated experience conducting Life Safety assessments and mock surveys.
- Strong technical understanding of healthcare building systems and regulatory documentation.
Nice To Haves
- Certified Life Safety Specialist – Healthcare (CLSS-HC) strongly preferred
- CHFM, CHC, or other healthcare regulatory certification
- Experience in behavioral health compliance environments
Responsibilities
- Conduct comprehensive Life Safety Code (NFPA 101) assessments of healthcare facilities.
- Perform detailed evaluations of fire-rated assemblies, means of egress, hazardous areas, fire and smoke barriers, and life safety features.
- Identify deficiencies and provide prioritized corrective action recommendations.
- Review compliance with NFPA 99, emergency power systems, medical gas systems, and fire protection systems.
- Lead full-scale mock surveys aligned with: The Joint Commission (TJC) CMS Conditions of Participation DNV (as applicable) State Department of Health requirements
- Evaluate documentation, policies, testing and inspection records, and compliance processes.
- Prepare executive leadership and department leaders for regulatory survey interaction.
- Deliver formal reports outlining findings, risk levels, and remediation plans.
- Conduct on-site field verification surveys to support Life Safety drawing and plan development.
- Validate life safety features against architectural life safety plans.
- Identify discrepancies between existing conditions and documented drawings.
- Support development of Statements of Conditions (SOC) and Plans for Improvement (PFIs).
- Conduct ligature risk assessments in behavioral health and high-risk healthcare environments.
- Evaluate patient rooms, bathrooms, common areas, and ancillary spaces for environmental risks.
- Provide mitigation strategies consistent with regulatory and accreditation guidance.
- Assist organizations in documenting risk decisions and mitigation plans.
- Perform regulatory gap analyses related to the healthcare physical environment.
- Support development of corrective action roadmaps with measurable milestones.
- Provide consulting services related to: Environment of Care (EOC) Life Safety (LS) Emergency Management Interim Life Safety Measures (ILSM)
- Provide executive-level summaries and compliance strategy recommendations.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Career Level
Director
Number of Employees
1-10 employees
