3 Primary Goals of Compliance & Ethics Programs
SNF Compliance and Ethics Program must be in place by November 28, 2019 after which State survey agencies will begin assessing facility implementation.
Effective compliance programs need to accomplish three primary goals
- Prevent, detect, and correct illegal or non-compliant behavior – to ensure the highest standards of quality care.
- Provide safe mechanisms for reporting and seeking help with compliance related questions or concerns.
- Strong programs help to set expectations and raise awareness of what those expectations are. It is estimated that 98% of non-compliance is because the person either did not know or the expectations were unclear.
To successfully achieve these objectives, each organization’s program must be tailored to meet its unique needs, size and complexity. The program must also continually evolve and adapt to organizational needs as laws and regulations change over time. Simply creating a binder labeled “Compliance Program” with written Policies and Procedures on the shelf doesn’t meet the standard when those procedures are not implemented and actively applied.
How Do I Ensure My Compliance Program is Effective?
- Understand the seven core elements that should be implemented to deem a compliance program effective.
- Develop written compliance and ethics standards, policies, and procedures and updated them periodically.
- Designate a Compliance Officer* or Designee and establish a Compliance Committee. The Compliance Officer’s role should be separate from operations whenever possible and include thoughtful lines of authority to allow for some level of independence in managing the program. The Compliance Officer should be comfortable reporting to the board, proficient in clearly assessing compliance risks and have the expertise and problem solving skills to lead the facility in implementing solutions.
- Establish routine compliance and ethics training. Communicate the goal of your facility’s culture of compliance. Compliance training is generally recommended for new employees, contractors, and volunteers as relevant to their specific job roles as part of orientation and at least annually thereafter. See the final rule for specific communication standards included as part of the phase 3 requirements of participation (RoP).
- Develop a method of reporting violations. Staff must be aware of appropriate lines of communication (ie. Open door policy, email, hotline, etc). as well as the facility policy of non-retaliation for reporting potential violations.
- Auditing & Monitoring. Your auditing and monitoring plan should be based on facility-specific risks that include identified situations, and processes that may cause harm to your organization. Auditing is often accomplished through a 3rd party or a department outside of the service area being reviewed. Monitoring includes quality check processes that normally take place as part of routine daily operations.
- Violation response plan & investigations. Reasonable steps to prevent or deter non-compliant behavior are important. A system should be in place for the Compliance Officer or designee to receive notification of complaints and for tracking those issues. Investigations need to be initiated based on the assigned priority level and timeframe.
- Disciplinary standard enforcement. Employees need to know the consequences of non-compliance and should understand that action will always be taken to enforce compliance standards consistently across the organization.
- Annual Review. A compliance program is never finished; it should always be a work in progress. Periodic reviews for program effectiveness should be conducted at least annually; in many cases, 3rd party reviews are optimal.
*For organizations with five or more facilities, RoP Phase 3 requires that a compliance officer be designated whose major job responsibility is operating the compliance program, and that compliance program liaisons be designated at each facility to support the compliance officer in ensuring that the compliance program is understood and effectively disseminated throughout various facilities in the organization. For chains of five of more facilities these requirements are in addition to the eights required components and the requirement to conduct an annual review of the program.
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Blog by Stacy Baker, OTR/L, CHC, RAC-CT, Proactive Medical Review
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