Manager, Facilities – Life Safety Compliance

Job Responsibilities: Regulatory/Compliance Inspection, Testing and Maintenance Documentation:

• In collaboration with EH&S, ensure properties are managed in compliance with all applicable NYULH policies, federal, state and local laws, codes and standards, including any requirements of third-party regulators such as NYS DOH, The Joint Commission (TJC), CMS, FDNY, EPA, CDC and others including authorities having jurisdiction. Note that communication with regulators will be determined by EH&S
• Overseeing the collection and organization of documentation from required life safety inspection, testing and maintenance activities, and providing this data for presentation at monthly meetings of the NYULH System Environment of Care Committee, system hospital Sub-Committees, and Evidence of Standards Compliance (ESC), as required;
• Ensuring adequate/compliant inspection, testing & maintenance of fire alarm & protection systems, and appropriate response to impairments, including fire watch, and maintaining compliant records (3 years)
• Serving as departmental liaison during accreditation surveys by The Joint Commission and other regulatory agencies in connection with healthcare facilities life safety;
• Representing the off-site portfolio at regulatory and other compliance meetings enterprise-wide;
• Monitoring vendor maintenance responsiveness and overall performance, following the RED+F procurement policy and procedures for life safety vendors, working with Project Support Office (PSO), EH&S (where applicable) and/or Supply Chain Management (SCM) to identify qualified vendors and negotiate scope and best possible pricing;
• Maintaining appropriate documentation and records related to all supplies, vendors, contracts, and project work, and communication in an inspection-ready state at all times;
• Interfacing and supporting other departments at NYULH including Facilities Operations, Engineering, Environmental Health & Safety, Infection Prevention & Control, MCIT, Security, Design/Construction, FGP, Insurance, Finance, Environmental Services and others;
• Participating in periodic review of institutional Management Plans, safety policies and protocols, and contributing to policy updates and formulation;
• Engaging in special projects and initiatives, and performing other duties as assigned.

NYU Portfolio-Wide Regulatory Compliance:

• Providing leadership, direction and supervision in a matrixed organization, collaborating and working together with Facilities Managers, Facilities Operations, EH&S, departmental staff and vendors to develop preventive maintenance and inspection procedures to accomplish life safety compliance goals;
• Evaluates site conditions in context of NYULH Safety Policies, Fire Safety Handbook, Construction Safety Policy and applies these requirements to address life safety concerns relating to the physical environment. Consults with EH&S for guidance as appropriate and necessary.
• Assists with the management of TJC, CMS, DOH, EPA, CDC, UHMS, AAAASF (Quad A), DNV and other regulatory inspections for off-site portfolio; coordinating required response and implementing corrective actions as approved by NYULHs Regulatory Department and other relevant stakeholders (e.g., EH&S, Infection Prevention and Control, etc.) ;
• Coordinating the response to clear open municipal Violation Orders (VO), collaborating with Real Estate and/or Facilities Operations staff[MF1] , vendors and New York University to address underlying defects and conditions;
• Collaborating with the Real Estate transactions team[MF2]  to evaluate potential sites for life safety and ADA compliance to support acquisition and lease negotiations; confirming that recommendations from compliance assessments are addressed prior to occupancy, whenever possible;
• Ensure compliant inspection, testing, and maintenance of fire extinguishers.
• Collaborating with EH&S and EM+ER to develop, monitor, review for accuracy, and routinely train off-site staff and fire response teams on the fire and emergency action plans, ensuring that landlords are within compliance and occupants[MF3]  are aware of the Plan and know what to do in case of emergency;
• In collaboration with EH&S, investigate fire alarms & incidents: investigate smoke/fire incidents within 48 hours, complete incident reports, inform hospital administration if patient impact, implement corrective actions, maintain records of all alarms and incidents, provide records to EH&S
• Overseeing staff activities relating to cooling towers, generators, elevators, fire alarm panels and other life safety building systems/equipment to ensure compliance with municipal regulations;
• Ensuring that fire and evacuation drills for staff are properly scheduled and conducted as required (e.g., frequency, times, unannounced, occupancy requirements) by qualified/certified staff/vendor, and documented for the entire portfolio, including residential locations;
• Assisting Project Managers with the implementation of complex upgrades and installations, providing project management support, and in consultation with EH&S, providing technical consulting on capital projects and guidance on regulatory interpretations as needed;
• Establishing and posting Interim Life Safety Measures (ILSM) when necessary and providing relevant, timely communications to RED+F senior leadership, Chief Regulatory Officer, EH&Sand others as required;
• Administering the internal permitting process for various construction activities pertaining to life safety including hot work, barrier integrity, utilities shutdowns, above- ceiling and other construction-related activities requiring safety permits;
• Ensuring that Compliance staff complete necessary compliance/safety trainings and providing opportunities for additional training;
• Supporting the quarterly Focused Standards Assessment (FSA) through The Joint Commission Resources Tracers with AMP.
• Developing and managing annual budgets for Life Safety Compliance activities.

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