Healthcare Director of Life Safety & Regulatory Compliance - Lexington, KY

Job Description

Job Description

​Salary:  $150K to $175K

Other Forms of Compensation:   Yearly Bonus Potential  

Healthcare Director of Life Safety & Regulatory Compliance - UK HealthCare

Crothall Healthcare , a Compass Healthcare company, provides specialized, high-quality, innovative, and responsive support services exclusively to the healthcare industry. Crothall serves many of the Top 100 Hospitals throughout its over 900 hospital partners across 46 states. Crothall has been recognized as one of Modern Healthcare’s Best Places to Work and Best Places to Work in Pennsylvania since 2013. Crothall has more than 32,000 team members, with core services include: Environmental Services, Patient Transportation, Patient Observation, Healthcare Facilities Management, Sterile Processing Services, and Ambulatory EVS. Learn more at

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.

Apply to Crothall today!

Crothall is a member of Compass Group USA

Click here to Learn More about the Compass Story

Associates at Crothall are offered many fantastic benefits. 

• Medical
• Dental
• Vision
• Life Insurance/ AD
• Disability Insurance
• Retirement Plan
• Flexible Time Off
• Holiday Time Off (varies by site/state)
• Associate Shopping Program
• Health and Wellness Programs
• Discount Marketplace
• Identity Theft Protection
• Pet Insurance
• Commuter Benefits
• Employee Assistance Program
• Flexible Spending Accounts (FSAs)
• Paid Parental Leave
• Personal Leave

Associates may also be eligible for paid and/or unpaid time off benefits in accordance with applicable federal, state, and local laws. For positions in Washington State, Maryland, or to be performed Remotely, click here or copy/paste the link below for paid time off benefits information.

-usa.com/wp- content/uploads/2023/08/2023_WageTransparency_Crothall.pdf

Compass Group is an equal opportunity employer. At Compass, we are committed to treating all Applicants and Associates fairly based on their abilities, achievements, and experience without regard to race, national origin, sex, age, disability, veteran status, sexual orientation, gender identity, or any other classification protected by law.

Qualified candidates must be able to perform the essential functions of this position satisfactorily with or without a reasonable accommodation. Disclaimer: this job post is not necessarily an exhaustive list of all essential responsibilities, skills, tasks, or requirements associated with this position. While this is intended to be an accurate reflection of the position posted, the Company reserves the right to modify or change the essential functions of the job based on business necessity. We will consider for employment all qualified applicants, including those with a criminal history (including relevant driving history), in a manner consistent with all applicable federal, state, and local laws, including the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, and the New York Fair Chance Act. We encourage applicants with a criminal history (and driving history) to apply.

Certain positions may require Florida Level 2 background screening. Details:

Applications are accepted on an ongoing basis.

Crothall maintains a drug-free workplace.

Req ID: 1574644

Crothall Healthcare 

SHANNON MOORE 

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