May 15, 2018



The Compliance Team was started because of my experience in accreditation with the “wrong way of doing it.”

Before I started The Compliance Team in 1994, my experience with standards and other Accreditation Organizations, was that they were focused on the policies and procedures and not on care and service. That certainly was contrary to my beliefs as a registered nurse, where the patient always came first! Healthcare standards should be easy to understand, so that the providers AND the patients can understand what healthcare providers are held accountable for. The Compliance Team’s standards are easier to understand yet meet and/or exceed CMS (Centers for Medicare and Medicaid) requirements.

Learn more about how our standards can benefit you by reading our article, “When Simple is Best.”

Best Regards,

Sandra C. Canally, RN
Founder and Chief Executive Officer

When simple is best.

The Compliance Team was the first accreditation organization (AO) to develop a simplified plain-language set of standards. Accreditation simplification isn’t about what you give up or lose; accreditation simplification is about what you gain during the accreditation process and how it facilitates on-going excellence. Simplification leads to clarity and clarity allows providers to focus on what matters most –healthcare excellence, or, what we call Safety-Honesty-Caring®.

At the heart of The Compliance Team and the foundation of our accreditation programs are two key beliefs: (1) that every patient deserves exemplary care and (2) that accreditation should not be difficult or costly to attain. The Compliance Team organized the standards so that there is a universal set of standards for every accreditation program and then specialty standards that concentrate on the unique services of the program. Organizing the standards this way, across every platform, assures that all providers achieve operational excellence, which leads to clinical excellence. The Compliance Team was the FIRST accreditation organization to focus on operations-driven standards. This is still in effect after 24 years.

The Compliance Team’s core mission is to promote healthcare excellence through the implementation of sustainable quality improvement measures that simplify the accreditation process and establish Safety-Honesty-Caring® as core patient relationship goals.

  1. The Compliance Team’s standards are all based on a universal set of easy-to-understand elements inherent in each accreditation program, such as having: a written Corporate Compliance Plan, standards of conduct, written policies and procedures. From day one, this core information is easy for the provider to understand and implement. Simplifying the standards saves YOU time and money.
  2. Because The Compliance Team’s accreditation programs are operations-based, the standards are flexible enough to integrate the evidence of compliance into the clinic’s existing operation. This ensures you are more likely to successfully maintain your accreditation and makes it easier for your employees to implement – a Win-Win for all concerned.
  3. The Compliance Team program incudes self-assessment checklists and easy access to accreditation advisors and the executive team to help keep you on the Exemplary Provider track. If you are following the correct procedures and processes on an on-going basis, you can have confidence in a successful accreditation visit. This makes it more likely for you to stay on track and maintain your subsequent visits from The Compliance Team.

The Compliance Team’s proprietary Exemplary Provider Certificate of Excellence is awarded to those organizations that pass our rigorous evidence of compliance. Our easy-to-understand standards make this a goal that every clinic can accomplish. We at The Compliance Team encourage every clinic to contact us to see how their operation can become an accredited Exemplary Provider.

Find out first hand from some of our clients who are the best voices to explain why simple is best. Contact The Compliance Team and we will provide you with a customer whom you may contact.


In this video Kate Hill talks about a common deficiency around Emergency Preparedness

Common Deficiencies in a Clinic Environment

Contact Kate Hill, V.P. of Clinical Services

Failure to conduct a second Emergency Preparedness exercise annually

The regulations at 42 CFR §491.12(d)(2) requires Rural Health Clinic’s (RHCs) to test their Emergency Preparedness plans by conducting two exercises annually. The first exercise is a full-scale community-based exercise or when a community-based exercise is not available, an individual facility-based exercise.  The second exercise can be a second full-scale exercise that is community-based or individual facility-based OR a tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages or prepared solutions designed to challenge an emergency plan.  Some examples of a Tabletop Emergency Preparedness Exercise can be found at the FEMA website at

In conclusion, RHCs must test their Emergency Preparedness plan by conducting two exercises per year.  Please note that participation in the hospital’s Emergency Preparedness exercise will count as only one exercise for provider-based RHCs.  Also, to provide evidence of participation, Rural Health Clinics must maintain documentation of all exercises and emergency events.

Questions may be directed to Kate Hill, RN at


“We use the Compliance Team and are VERY HAPPY with them, their services, professionalism, promptness and wanting to help us pass each inspection. I HIGHLY recommend them.”

– Kari LeMert-Fernandez RN, BSN, Director, Pioneers Health Center, Brawley, CA

Exemplary Provider Decals

We have new Exemplary Provider digital decals that you can add to your website or to your marketing materials. You can choose between generic or custom decals that include the accreditation tracks e.g. DMEPOS, Community Rx + DMEPOS, Long Term Care Pharmacy, Specialty Drug. Contact Marilyn, our communications advisor, for details,

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