Services Advisory & Fractional CCO | Ethoshield
Advisory Services

Executive-level compliance
leadership, built to scale

Fractional and advisory models that give independent healthcare organizations senior compliance expertise without the cost or commitment of a full-time hire.

Fractional Chief Compliance Officer
Most requested

Strategic compliance oversight at the executive level without the cost of a full-time hire. We partner directly with ownership and leadership to establish governance structures, conduct risk assessments, strengthen internal controls, and provide regulatory guidance aligned with operational priorities.

For nursing facilities, this means a compliance officer who understands CMS conditions of participation, survey processes, MDS documentation, and Medicare billing not just generic healthcare law.

What’s included

  • Executive-level compliance leadership with direct reporting to ownership
  • Organizational risk assessment aligned to OIG GCPG and nursing facility ICPG
  • Governance structure design including board-level reporting
  • Internal controls review and gap analysis
  • Ongoing regulatory guidance and change management
  • Incident response leadership and corrective action oversight
  • OIG exclusion screening program management
GovernanceRisk assessmentOIG alignmentNursing facility
Compliance Infrastructure & Program Design

Development and refinement of tailored compliance frameworks policy architecture, reporting mechanisms, training strategy, and internal review protocols. Our focus is not volume; it is defensible structure and operational clarity.

We design programs your staff can actually follow, your leadership can explain, and that hold up when regulators ask to see them.

What’s included

  • Code of conduct and policy manual development or revision
  • Anonymous reporting hotline setup and non-retaliation policy
  • Internal audit and monitoring schedule design
  • Compliance committee structure and charter
  • Corrective action and disciplinary procedure documentation
  • Training program architecture and content framework
  • Documentation and recordkeeping protocols
Policy designHotline setupAudit protocolsDocumentation
Ongoing Advisory & Risk Mitigation

Targeted regulatory guidance and practical risk oversight for organizations navigating growth, operational changes, or heightened regulatory attention. We serve as a steady compliance partner when leadership needs clarity, not complexity.

Particularly valuable when responding to a survey finding, expanding services, adding locations, or managing a billing audit.

What’s included

  • Ongoing regulatory monitoring and interpretation
  • Incident and complaint intake, triage, and response
  • Survey preparation and post-survey corrective action planning
  • Billing and claims risk review
  • Third-party contract and arrangement review for AKS compliance
  • Self-disclosure evaluation and support
  • Monthly or quarterly compliance reporting to leadership
Regulatory guidanceRisk monitoringSurvey response
CLIA Inspection Readiness

Comprehensive mock inspections and documentation review designed to prepare laboratory environments for regulatory scrutiny. We identify vulnerabilities, guide corrective action planning, and ensure leadership understands both risk exposure and remediation pathways.

What’s included

  • Full mock CLIA inspection using current CMS inspection protocols
  • Documentation and recordkeeping gap analysis
  • Personnel qualification and training record review
  • Quality control and quality assurance procedure review
  • Proficiency testing compliance assessment
  • Corrective action plan development and tracking
  • Leadership debrief and remediation priority mapping
Mock inspectionDocumentation reviewCLIALaboratory
Common questions

How the engagement works

How is a fractional CCO different from a compliance consultant? +
A compliance consultant typically delivers a project an assessment, a policy document, a training and exits. A fractional CCO is an ongoing leadership role. We attend leadership meetings, respond to incidents, adjust the program as your organization changes, and are accountable for the compliance function over time. The OIG expects organizations to have designated compliance leadership with real authority a one-time consulting engagement doesn’t satisfy that expectation.
What size organizations do you work with? +
We work primarily with independent and small-group healthcare organizations nursing facilities, assisted living operators, home health agencies, clinical labs, and independent physician practices that don’t have the volume or budget to justify a full-time compliance officer but have real regulatory exposure that demands one. Typically organizations with 10 to 500 employees.
How long does it take to build a compliance program from scratch? +
A foundational compliance program risk assessment, written standards, reporting mechanism, training plan, and audit schedule typically takes 60 to 90 days to design and implement for a nursing facility of average complexity. We can accelerate elements if you’re facing a specific deadline (survey, CMS review, or state audit). Implementation never really ends; ongoing monitoring and refinement are part of the program.
Do you work with organizations that already have some compliance infrastructure? +
Yes most engagements involve organizations that have something in place but recognize it isn’t sufficient. We assess what exists, identify structural gaps, and build from what’s already working. We don’t start from scratch unless the existing program is so outdated it creates more risk than it mitigates.
What does an engagement typically cost? +
We structure engagements based on scope, organization size, and complexity of your risk profile not hourly billing. Reach out for a conversation and we’ll give you a straightforward picture of what an engagement would look like for your organization.

Not sure which service fits?

We’ll start with a conversation and tell you exactly what your organization needs and what it doesn’t.

Talk to us →
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