Facilities Compliance Associate

The Facilities Compliance Associate is responsible for supporting the safe, compliant, and efficient operation of the outpatient surgery center's physical environment. This role helps ensure compliance with applicable federal, state, local, and accreditation standards, including those established by CMS, AAAHC and other regulatory agencies. The Facilities Compliance Associate coordinates facility inspections, preventive maintenance activities, safety programs, environmental rounds, and documentation to support regulatory readiness and patient safety. This role reports directly to the CEO with a dotted line to the Director of Operations. 

Supervisory Responsibilities: 

No 

Duties and Responsibilities: 

Regulatory Compliance & Accreditation 

• Assist with maintaining compliance with CMS Conditions for Coverage and applicable accreditation standards.  
• Coordinate and document facility compliance activities, inspections, and corrective action plans.  
• Maintain regulatory records and compliance documentation for surveys, audits, and inspections.  
• Support preparation for accreditation and regulatory surveys.  
• Monitor and track compliance with life safety, environment of care, and infection prevention requirements related to the facility.  

Facilities Operations 

• Coordinate preventive maintenance schedules for building systems, equipment, and utilities.  
• Monitor facility work orders and assist in tracking completion of repairs and maintenance activities.  
• Conduct routine facility inspections to identify safety hazards, maintenance issues, and compliance concerns.  
• Assist with vendor management, including scheduling service providers and maintaining service records.  
• Support emergency preparedness planning and facility-related drills.  

Safety & Environment of Care 

• Participate in Environment of Care and Safety Committee activities.  
• Conduct environmental rounds and document findings.  
• Assist in maintaining compliance with OSHA standards, including hazard communication and workplace safety programs.  
• Monitor fire safety systems, emergency exits, utility management, and life safety requirements.  
• Track and coordinate corrective actions resulting from safety inspections and incident investigations.  

Documentation & Reporting 

• Maintain organized records of inspections, testing, maintenance activities, permits, certifications, and regulatory documentation.  
• Prepare reports and compliance metrics for leadership review.  
• Track deadlines for required testing, certifications, and preventive maintenance activities.  
• Assist with policy and procedure updates related to facilities and safety compliance.  

Emergency Preparedness 

• Support the implementation and maintenance of the Emergency Operations Plan.  
• Assist with conducting emergency preparedness drills and documenting outcomes.  
• Maintain emergency equipment inventories and readiness documentation. 

Education 

• Associate degree in Healthcare Administration, Facilities Management, Environmental Health & Safety, Business Administration, or related field preferred.  
• High school diploma or equivalent required. 

Experience 

• Minimum of 2 years of experience in healthcare facilities, compliance, safety, operations, or related field preferred.  
• Experience in an ambulatory surgery center, hospital, or healthcare environment strongly preferred.  
• Familiarity with accreditation and regulatory requirements for healthcare facilities preferred.  

Knowledge, Skills, and Abilities 

• Working knowledge of OSHA, CMS, AAAHC, The Joint Commission, NFPA, and healthcare facility regulations.  
• Strong organizational and documentation skills.  
• Ability to manage multiple projects and deadlines simultaneously.  
• Proficiency with Microsoft Office Suite and facility management/compliance software.  
• Strong analytical and problem-solving skills.  
• Excellent written and verbal communication skills.  
• Ability to work independently and collaboratively with clinical and administrative staff. 

ADA Job Requirements: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Physical Demands: Intermittent lifting if equipment and instructions up to 50lbs. Walking, standing, lifting, reaching with hands and arms, carrying, stooping, kneeling, crawling, bending, squatting, handling, use hands to finger, handle, or feel, prolonged sitting, vision, eye-hand coordination, tasting or smelling. The employee is occasionally required to climb or balance. Specific vision abilities required by this job include close vision, distance, vision, color vision, peripheral vision and depth perception. 

Communication Skills: Writing, speaking, hearing, reading, interpersonal relationships, receiving instructions, giving instructions. 

Intellectual Skills: Short and long term memory, abstract reasoning, decision making, directing others, mathematical calculations. 

Work Situations: Work Situations: Working as part of a group, working with the public, performing a variety of duties, use of technology. 

Disclaimer: 

This job description indicates the general nature and level of work expected of the incumbent. It is designed to cover or contain a comprehensive listing of activities, but not all-inclusive, listing of activities, duties or responsibilities required of the incumbent. Incumbent may be asked to perform other duties as required. See ADA checklist for specific related criteria.