Life Safety Manager

The Life Safety Compliance Manager [Emergency Preparedness & Environment of Care] is responsible for leading system-wide programs that ensure a safe, compliant, and resilient environment for patients, staff, and visitors across all healthcare facilities.

This role oversees Life Safety compliance, Emergency Preparedness planning, Environment of Care (EOC) standards, and regulatory readiness in accordance with federal, state, and accreditation requirements. The position ensures ongoing compliance with applicable standards including CMS Conditions of Participation, state regulations, and accreditation bodies such as The Joint Commission and other applicable agencies.

The ideal candidate brings strong operational experience in safety, emergency response, fire prevention, or law enforcement, with the ability to translate real-world incident response and risk mitigation into healthcare compliance systems.

ESSENTIAL RESPONSIBILITIES:

Life Safety Program Management

• Lead and manage the organization’s Life Safety compliance program across all facilities.
• Ensure compliance with applicable fire safety codes, including the NFPA Life Safety Code (NFPA 101) and related standards.
• Conduct routine Life Safety assessments, audits, and inspections across clinical and non-clinical areas.
• Identify deficiencies and ensure corrective actions are implemented and sustained.
• Maintain documentation required for Life Safety surveys, inspections, and regulatory reviews.
• Partner with facilities, construction, and engineering teams on Life Safety design and renovation projects.

Emergency Preparedness Program Oversight

• Develop, implement, and maintain comprehensive Emergency Preparedness (EP) plans for all facilities.
• Ensure compliance with CMS Emergency Preparedness Rule requirements.
• Coordinate drills, tabletop exercises, and real-event response evaluations.
• Evaluate emergency response readiness for events including natural disasters, active threats, mass casualty incidents, utility failures, and infectious disease emergencies.
• Serve as a key leader during emergency activation events and system-wide response coordination.
• Conduct after-action reviews and develop improvement plans following drills or real events.

Environment of Care (EOC) Oversight

• Oversee Environment of Care programs ensuring safe physical environments for patients, staff, and visitors.
• Monitor compliance in areas including:
• Safety management
• Security management
• Hazardous materials and waste
• Fire safety
• Medical equipment safety
• Utilities management
• Conduct routine EOC rounds and audits across all facilities.
• Ensure compliance with accreditation and regulatory standards related to environment of care.

Regulatory Compliance & Survey Readiness

• Maintain readiness for regulatory surveys, inspections, and accreditation visits.
• Support compliance with CMS, state health departments, and accrediting organizations.
• Prepare documentation, reports, and corrective action plans for deficiencies.
• Coordinate responses to survey findings and ensure timely resolution of issues.
• Track regulatory changes and update policies, procedures, and programs accordingly.

Incident Response & Risk Mitigation

• Investigate safety incidents, environmental risks, and emergency events.
• Conduct root cause analysis and develop corrective action plans.
• Identify system-wide risks and recommend mitigation strategies.
• Collaborate with Risk Management, Compliance, Facilities, and Clinical Leadership to reduce safety hazards.

Training, Drills & Staff Education

• Develop and conduct training programs related to Life Safety, Emergency Preparedness, and Environment of Care.
• Coordinate mandatory drills including fire drills, evacuation exercises, and emergency response simulations.
• Provide education to clinical and non-clinical staff on safety procedures and emergency response protocols.
• Promote a culture of safety, preparedness, and accountability across all facilities.

Cross-Functional Collaboration

• Partner with Facilities, Security, Clinical Operations, Nursing Leadership, IT, and Executive Leadership.
• Collaborate with construction and renovation teams to ensure compliance with safety and fire codes.
• Serve as liaison with external agencies including fire departments, emergency management agencies, and regulatory bodies.
• Participate in safety committees, compliance committees, and leadership meetings.

Reporting & Documentation

• Maintain Life Safety, Emergency Preparedness, and EOC documentation systems.
• Develop dashboards, reports, and compliance summaries for executive leadership.
• Track corrective actions, audit findings, and drill performance metrics.
• Present findings and recommendations at leadership and compliance meetings.
• Other duties as assigned

QUALIFICATIONS:

Education

• Bachelor’s degree in Healthcare Administration, Emergency Management, Public Safety, Environmental Safety, or related field required.
• Master’s degree preferred.

Experience

• Minimum 5–7 years of experience in one or more of the following:
• Hospital Life Safety / Environment of Care
• Emergency Preparedness / Emergency Management
• Fire Safety Planning / Fire Marshal operations
• Law enforcement, military, or public safety leadership
• Healthcare compliance or hospital operations experience strongly preferred.
• Experience in multi-site healthcare systems preferred.

Preferred Certifications

• Certified Healthcare Protection Administrator (CHPA)
• Certified Emergency Manager (CEM)
• Certified Healthcare Safety Professional (CHSP)
• OSHA Safety Certifications
• Fire Safety or NFPA-related training certifications

Knowledge, Skills, and Abilities

• Strong understanding of healthcare Life Safety and Emergency Preparedness regulations.
• Knowledge of NFPA standards and healthcare building safety requirements.
• Ability to assess physical environments and identify safety risks.
• Strong leadership skills in high-pressure or emergency situations.
• Experience in incident command systems (ICS) or emergency operations centers (EOC).
• Excellent communication and training skills.
• Ability to work across clinical, operational, and administrative departments.
• Strong analytical and investigative skills.

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