Salary: $80K to $90K

Other Forms of Compensation:$3K Yearly AD Bonus Potential

Assistant Director of Regulatory Compliance - UHS Chenango Memorial Hospital

Job Summary

The Assistant Director of Facilities Management - Regulatory Compliance serves as a key leader within Facilities Management, responsible for overseeing regulatory compliance, Environment of Care (EOC), Life Safety, Emergency Management, and accreditation readiness programs across the healthcare organization.
Essential Duties and Responsibilities
Regulatory Compliance & Accreditation
• Coordinate and maintain compliance with TJC, CMS, NFPA, OSHA, EPA, and state requirements.
• Lead readiness activities for accreditation surveys, inspections, and audits.
• Conduct compliance assessments and implement corrective actions.
Environment of Care (EOC)
• Manage EOC programs and documentation.
• Conduct EOC rounds and track improvement initiatives.
• Participate in EOC Committee activities.
Life Safety & Emergency Management
• Oversee fire safety, drills, ILSM, and life safety compliance.
• Support emergency preparedness planning and exercises.
• Manage deficiency tracking and Plans for Improvement.
Facilities Operations Support
• Partner with engineering and facilities teams to integrate compliance into operations.
• Monitor maintenance documentation and compliance reporting.
Quality Improvement & Reporting
• Develop compliance metrics, dashboards, and reports.
• Lead root cause analysis and continuous improvement efforts.
Leadership & Staff Development
• Provide education on EOC, Life Safety, and regulatory standards.
• Mentor staff and promote accountability and safety.
Required Qualifications
• Bachelor's degree in related field.
• 5+ years of healthcare facilities, compliance, engineering, or accreditation experience.
• Knowledge of TJC, CMS, NFPA, OSHA, and EPA standards.
Preferred Qualifications
• Master's degree preferred.
• CHFM, CHC, CHSP, or CHESP certification.
• Lean Six Sigma or process improvement experience.
Core Competencies
• Regulatory Compliance
• Joint Commission Readiness
• Environment of Care
• Life Safety Compliance
• Emergency Management
• Project Management

Apply to Crothall today!

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.

https://www.compass-usa.com/wp-content/uploads/2023/08/2023_WageTransparency_Crothall.pdf

Req ID: 1566290

Crothall Healthcare

Abigail Van Eman

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