The Engineering Compliance Manager is responsible for the technical oversight, administration, and execution of facility engineering Physical Environment compliance programs, including required testing, inspections, and associated documentation in accordance with The Joint Commission, Centers for Medicare & Medicaid Services, Texas Administrative Code (TAC), Texas Department of Licensing and Regulation, Texas Commission on Environmental Quality, and Environmental Protection Agency requirements.
This role ensures system-wide compliance across the JPS Network related to Facilities Engineering Operations by maintaining program integrity, regulatory readiness, and audit support. The position operates as a technical subject matter expert, working in coordination with the Director of Environmental Health and Safety to support compliance with Physical Environment standards. Essential Job Functions & Accountabilities: Assists the Director of Environment Health and Safety, oversee the management of the facilities engineering specific compliance documentation to ensure all regulatory documentation as required under Joint Commission (JC) and the Centers for Medicare and Medicaid Services (CMS) are completed on time and completed accurately.
Partners with the Director of Facilities Engineering the development and maintenance of the appropriate testing and inspection timelines for the entire calendar year to ensure compliance with JC and CMS. Partners with the Director of Facilities Engineering in the development of regulatory compliance training for facilities engineering leadership and staff. Oversees the finalization and along with the Director of Facilities Engineering the management verification of current inventories, testing schedules and results, and corrective maintenance history required for Emergency power systems, fire systems, and medical gas systems.
Ensures all documentation is current and accurate while confirming all regulatory and required testing is completed within the proper schedule by working with staff and department leadership. Supports the review and completion of the Utilities Management Plan, Utility Failure Plans, Shutdown procedures, etc. for compliance and operational success along with the Director of Facilities Engineering. Reports information to the Physical Environment Committee.
Maintains and completes annual reviews of the Statement of Conditions and Basic Building Information as it pertains to changes in square footage allocation for the JPS network. Oversees and completes required building assessments as a representative for Facilities Engineering to ensure compliance through department tracers and leadership tracers. Partners with the Engineering department leaders to manage survey action plans and tracking of all compliance related work orders and preventative maintenance activities.
Establishes and manages network standards regarding UL assemblies and fire stopping. Assists in review of all facilities engineering department policies and procedures for regulatory compliance. Provides guidance and interprets new codes to inform staff and leadership of new and existing requirements and to prepare for upcoming surveys.
Assists in leading efforts of documentation review during all regulatory accreditation surveys along with the Director of Engineering and Director of Environmental Health and Safety. Trains Facilities Engineering leadership and staff along with the Environmental Health and Safety team related to compliance topics.
is not an all-inclusive list of duties and may be subject to change with or without notice. Staff are expected to perform other duties as assigned.