Director of Life Safety & Regulatory Compliance - Lexington, KY

Job Summary

The Director of Life Safety & Regulatory Compliance provides strategic leadership and oversight for life safety, environmental compliance, accreditation readiness, and regulatory compliance programs across the healthcare system. This position is responsible for ensuring compliance with all applicable federal, state, local, and accreditation standards related to healthcare facilities, environment of care, life safety, construction activities, and operational safety.

The Director serves as the organization's subject matter expert for The Joint Commission, CMS, NFPA, OSHA, and state regulatory requirements, leading proactive compliance initiatives that support patient safety, caregiver safety, operational excellence, and accreditation success.

This role partners closely with Facilities Management, Safety, Infection Prevention, Clinical Operations, Emergency Management, Engineering, Security, and Executive Leadership to ensure a safe and compliant healthcare environment.

Responsibilities:

Direct enterprise-wide regulatory compliance initiatives related to healthcare facility operations.
Develop long-term compliance strategies and corrective action plans.
Serve as primary point of contact for regulatory agencies, accreditation organizations, and surveyors.
Direct and oversee Life Safety Management Programs across all facilities.
Ensure compliance with Life Safety Code requirements and documentation standards.
Lead development and maintenance of Life Safety Drawings and Statements of Conditions.
Monitor fire protection systems, fire barriers, egress requirements, and life safety features.
Oversee life safety assessments, inspections, and compliance audits.
Lead organization-wide Environment of Care programs.
Chair or co-chair Environment of Care and Safety Committees.
Analyze and track compliance trends, risks, and performance metrics.
Ensure corrective actions are implemented and sustained.
Develop policies and procedures supporting a safe care environment.
Lead continuous readiness efforts for Joint Commission, DNV, HFAP, CMS, and state surveys.
Conduct mock surveys and compliance assessments.
Coordinate responses to regulatory findings and deficiencies.
Facilitate survey preparation activities across multiple facilities.
Drive enterprise-wide action plans for compliance improvement.
Identify emerging regulatory risks and compliance vulnerabilities.
Lead facility-related investigations following significant compliance events.
Partner with Risk Management and Patient Safety teams to implement preventive measures.
Support emergency preparedness, utility management, and business continuity initiatives.
Lead and mentor compliance, life safety, safety, and facilities compliance professionals.
Establish departmental goals, performance metrics, and development plans.
Manage departmental budgets and regulatory compliance resources.
Foster a culture of accountability, safety, and continuous improvement.

Qualifications:

Bachelor's degree in Engineering, Facilities Management, Construction Management, Safety, Healthcare Administration, Architecture, or related field.
Master's degree preferred.
8-12+ years of progressive healthcare facilities, life safety, regulatory compliance, or accreditation experience.
5+ years of leadership experience in a healthcare setting.
Experience leading compliance programs within acute care hospitals or complex healthcare systems.
Demonstrated success managing regulatory surveys and accreditation readiness initiatives.
CHFM, CHSP, SASHE and CSP certifications highly preferred.
Multi-hospital health system experience.
Experience leading Joint Commission, DNV, CMS, or state agency surveys.
Experience overseeing Life Safety Drawings and Statements of Conditions.