Comply
Comply compliance consultants standing together in a modern hospital corridor, lanyards visible, tablets in hand, composed confident expressions
Joint Commission · CMS CoP · State Licensure

Your Next Survey
Starts Here.

We translate thousand-page regulatory manuals into floor-ready checklists — guided by former surveyors who know exactly what the auditor will ask.

The Joint Commission (TJC)CMS Conditions of ParticipationState Licensure Renewals
See Our Survey Prep ProcessMeet the team
Est. 2009
850+ Facilities Surveyed
The Joint CommissionCMS Conditions of ParticipationState Licensure RenewalsLife Safety Code (LSC)SAFER® Matrix ComplianceTracer MethodologyMock Survey PreparationOPPE / FPPE BenchmarkingInfection Control TracersEmergency Preparedness (EP)Critical Access Hospital (CAH)Focused Standards Assessment
The Joint CommissionCMS Conditions of ParticipationState Licensure RenewalsLife Safety Code (LSC)SAFER® Matrix ComplianceTracer MethodologyMock Survey PreparationOPPE / FPPE BenchmarkingInfection Control TracersEmergency Preparedness (EP)Critical Access Hospital (CAH)Focused Standards Assessment
0+

Facilities Surveyed

Across 48 states

0+

Findings Resolved

With documented corrective plans

0%

First-Pass Accreditation

Among prepared clients

0+

Years Combined Experience

Clinical & regulatory

We cover
TJCThe Joint Commission
CMSCenters for Medicare & Medicaid Services
DNVDNV Healthcare
HFAPHealthcare Facilities Accreditation Program
CIHQCenter for Improvement in Healthcare Quality

The Bench

Not a Firm. A Team of Specialists.

Every domain covered by someone who has stood in the surveyor's shoes. Flip any card to see credentials, case counts, and a word from the consultant themselves.

Patricia Nguyen, infection preventionist in hospital scrubs, confident expression
IC Tracer Prep

Patricia Nguyen, RN, CIC

Infection Control Tracer Lead

19

Yrs Exp

142

Facilities

RNCICFormer TJC Surveyor
"Surveyors spend 40% of their IC tracer time at the hand hygiene station. We walk your team through exactly what that looks like — before they do."

Case Highlight

Led IC remediation at a 320-bed community hospital that had received a Requirement for Improvement in 3 consecutive surveys. Clean survey on next cycle.

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Robert Callahan, facilities engineer reviewing hospital corridor safety equipment
LSC Mock Rounds

Robert Callahan, PE, CHFM

Life Safety Code Specialist

24

Yrs Exp

208

Facilities

PECHFMFormer CMS SurveyorNFPA 101 Certified
"Life Safety Code findings account for nearly a third of all TJC citations. I spent 12 years writing those citations. Now I help you close them before the survey team arrives."

Case Highlight

Identified 47 LSC deficiencies at a CAH during mock rounds that would have generated an Immediate Threat to Life finding. All resolved prior to actual survey.

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Danielle Okafor, data analyst reviewing medical staff performance metrics on laptop
OPPE/FPPE Benchmarking

Danielle Okafor, MBA, CPHQ

Medical Staff Quality Analyst

14

Yrs Exp

97

Facilities

MBACPHQNAMSS Certified
"Most hospitals are collecting OPPE data but not benchmarking it against national percentiles. That gap is exactly what surveyors probe during the medical staff tracer."

Case Highlight

Built a standardized OPPE dashboard for a 5-hospital system that reduced medical staff tracer findings by 78% across all facilities within 18 months.

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Marcus Webb, nurse executive in hospital hallway reviewing compliance checklist on tablet
Nursing Tracer Prep

Marcus Webb, RN, MSN, NEA-BC

Nursing Standards Advisor

21

Yrs Exp

163

Facilities

RNMSNNEA-BCFormer CNO
"CNOs lose sleep over tracer rounds because they know their nurses know the care — but haven't rehearsed the compliance language. That's what we fix in the 90 days before your survey."

Case Highlight

Redesigned nursing competency documentation for a 480-bed teaching hospital, converting a 3-year pattern of nursing standard findings to zero deficiencies.

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Sofia Reyes, emergency preparedness consultant reviewing hospital incident command documentation
EP & HICS Compliance

Sofia Reyes, MPH, CHEP

Emergency Preparedness Lead

16

Yrs Exp

119

Facilities

MPHCHEPHICS CertifiedFormer State Surveyor
"EP is where small hospitals get blindsided. CMS Phase 2 requirements are still tripping up facilities that thought they were compliant. We find those gaps fast."

Case Highlight

Guided 14 critical-access hospitals through CMS Emergency Preparedness Rule compliance simultaneously, with all 14 passing initial CMS validation review.

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James Thornton, pharmacist reviewing medication management protocols at hospital pharmacy counter
Medication Mgmt Tracer

James Thornton, PharmD, BCPS

Medication Management Specialist

18

Yrs Exp

88

Facilities

PharmDBCPSASHP Fellow
"Medication management is TJC's most cited system tracer. I've sat on both sides of that table. The hospitals that score well aren't just compliant — they can explain their reasoning out loud."

Case Highlight

Reduced high-alert medication deficiency rate from 34% to 4% at a multi-campus health system through a 6-month tracer simulation program.

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Click any card to see credentials & case highlights

CMS Phase 1 Effective July 1, 2025

Ready to see exactly how we prepare a facility for survey?

Our Survey Prep Process page walks through every phase — from your initial gap assessment to the post-mock SAFER® Matrix report. Methodology, timelines, and what your staff will actually do differently on survey day.

See Our Survey Prep Process
No form on this page — just the methodology

Regulatory Coverage

Three Bodies. One Binder.

Compliance officers shouldn't need three different consultants for TJC, CMS, and state. We cover all three — with specialists who know the nuances between them.

TJC
Deadline Active

Full Accreditation Survey Prep

From the initial Focused Standards Assessment to the post-survey SAFER® Matrix report, we walk alongside your team through every phase of the three-year TJC accreditation cycle.

New SPG replaces SAG effective January 1, 2026

What We Deliver

  • Individual & Program-Specific Tracer Simulation
  • System Tracers: IC, Medication Mgmt, Data
  • SAFER® Matrix Gap Prioritization
  • Intracycle Monitoring (ICM) Support
  • Survey Process Guide (SPG) Alignment — Jan 2026
See how we handle TJC
CMS
Deadline Active

Conditions of Participation

Every hospital accepting Medicare or Medicaid must comply with 42 CFR 482. We interpret the interpretive guidelines so your policies — and your staff — are defensible on survey day.

CMS Phase 1 requirements effective July 1, 2025

  • CoP Policy & Procedure Gap Review
  • CMS Validation Survey Preparation
  • Deemed Status Maintenance
  • Phase 1–3 Rollout Compliance (2025–2027)
See how we handle CMS
EP
Deadline Active

EP Rule & HICS Compliance

CMS EP requirements trip up even prepared facilities. We audit your all-hazards plan, exercise documentation, and communication protocols against current CMS expectations.

Phase 2 requirements still catching facilities off-guard

  • All-Hazards Risk Assessment
  • HICS Plan Review & Update
  • Annual Exercise Documentation
  • CMS EP Validation Readiness
See how we handle EP
CAH

CAH-Specific Survey Readiness

Small hospital, same regulatory burden. We work with CAH CEOs who wear the compliance hat themselves — building practical, staff-sized systems that hold up under survey.

  • CAH Conditions of Participation Review
  • Rural Health Swing-Bed Compliance
  • Distance & Location Requirements
  • Single-Staff Compliance Program Design
See how we handle CAH
State

Licensure Renewal Readiness

State survey requirements vary by jurisdiction and change without fanfare. We track your state's inspection cadence and prepare the documentation packages your surveyors expect.

  • State Operations Manual Interpretation
  • Annual Licensure Renewal Prep
  • Deficiency Response & POC Drafting
  • Multi-State System Coordination
See how we handle State

Ready to start?

See the full methodology before you commit to anything.

See Our Survey Prep Process