Facilities Accreditation and Compliance Expert

2 weeks ago


San Antonio, Texas, United States GoldenWolf, LLC Full time
Job Title: Facilities Accreditation and Compliance Expert

We are seeking a highly experienced Facilities Accreditation and Compliance Expert to support the Defense Health Agency (DHA) Facilities Operations Branch (FOB) Program Manager.

Job Summary:

The successful candidate will serve as the Physical Environment and Life Safety Accreditation technical advisor, providing training, consultation, and ensuring compliance with fire safety, Statement of Conditions, and Environment of Care programs in accordance with the Joint Commission (TJC) and NFPA standards.

Key Responsibilities:
  • Plan, schedule, and provide in-person and virtual training sessions and consultations for Facility Managers (FMs) and Medical Treatment Facilities (MTFs) to ensure compliance with fire safety, Statement of Conditions, and Environment of Care programs.
  • Perform on-site and document reviews to assess compliance with TJC Environment of Care and Life Safety standards, including reviewing LS Drawings for compliance and project recommendations.
  • Assist in developing Plans of Action Memorandums (POAM) resulting from mock surveys and evidence of standards of compliance (ESC) from TJC accreditation surveys.
  • Respond to MTF questions regarding TJC standards, Life Safety Code (LSC), and other regulatory issues. Coordinate with DHA Fire Protection Engineers (FPEs) to resolve compliance-related issues.
  • Prepare budgetary estimates and justifications to secure program fiscal resources.
  • Develop and implement immediate and long-term goals, objectives, plans, and schedules to meet substantial changes in program authority and/or funding.
  • Develop, evaluate, and improve processes and procedures to monitor project/program efficiency and productivity. Make intensive analyses and propose program changes or regulatory revisions based on findings.
  • Represent DHA FOB at meetings, briefings, conferences, and hearings with higher headquarters, other federal agencies, state and local authorities, and the public.
Requirements:
  • Bachelor's Degree.
  • Minimum ten (10) years of demonstrated experience in medical facilities compliance with fire safety, Statement of Conditions, and Environment of Care programs per Joint Commission and NFPA standards, including five (5) years of technical experience with Environment of Care.
  • Certified Healthcare Facility Manager (CHFM) or Certified Healthcare Safety Professional (CHSP).
Preferred Skills:
  • Client-facing and internal communication skills.
  • Excellent written and verbal communication skills.
  • Strong organizational skills, attention to detail, and multitasking capabilities.
  • Proficiency with Microsoft Office, Smartsheet, Microsoft Project, Bluebeam Revu, or other project management platforms.
  • Healthcare Facilities Management experience.
  • Joint Commission Fellowship.
  • Knowledge of NFPA 99 and 101, TJC Life Safety Standards, TJC Environment of Care Standards, FGI Guidelines, and ASHRAE Standards.
  • Functional knowledge of DMLSS FM Module or other computerized maintenance management systems.
  • Familiarity with current National Fire Protection (NFPA) codes, OSHA requirements for medical facilities, facility condition inspections, real property inventory procedures, corrective action planning, and root cause failure analyses.
Additional Information:

This position requires significant travel to various MTF locations worldwide, up to 25-50% of the time.

U.S. Citizenship is required.

GoldenWolf, LLC offers a dynamic work environment, opportunities for professional growth, and the chance to contribute to impactful projects supporting military healthcare facilities.

We value innovation, excellence, and dedication in our team members. If you possess the qualifications and a passion for supporting healthcare operations, we invite you to apply.



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