Effective systems critical for a robust Compliance Program

A compliance program is made up of the written policies, procedures and day to day operational actions that focus on preventing and detecting violations of law and regulations and on promoting care quality.

The program should include an established framework for accountability, setting standards that outline expectations for following the rules and consistently “doing the right thing”, while promoting a culture of ethical practice across the organization. The concept of compliance encompasses the entire SNF operation across every department. The Compliance and Ethics Program involves developing formal mechanisms to drive the intangible concept of doing the right thing in a tangible way.

While the phase 3 requirements mandate that we implement a Compliance and Ethics program, voluntary compliance is just good business practice. Compliance and Ethics programs help to prevent, and when necessary, self-detect wrong-doing so that it can be corrected. Effective Compliance and Ethics Programs also encourage open dialogue and a safe method of reporting concerns, and also help set expectations and raise awareness of what the standards are—this is especially important since it is estimated that 98% of non-compliance is because the person either did not know or the expectations were unclear.(HCCA 2019).

The Phase 3 requirements for the Compliance and Ethics program are described at F895, an entirely new regulatory section, which becomes effective under Phase 3 in November 2019.

Effective systems for allowing complaints to be reported internally is critical to a robust Compliance Program; therefore, one of the phase 3 requirements involves having in place and publicizing a reporting system where compliance & ethics violations can be communicated anonymously. Reminders on how to report concerns should be communicated to employees, along with emphasis of the non-retaliation policy and the process for making anonymous reports. This can be accomplished through various means such as newsletters, orientation, annual compliance training, or posters in the facility. SNFs should also periodically validate that the reporting process (e.g. Hotline) is used and effective. For example, conduct mock calls to your hotline quarterly to ensure that the report is escalated and handled appropriately. Continually assess your team’s understanding of the compliance reporting process and never assume that no calls mean there are no potential concerns. In follow up to reports of potential compliance violations, conduct timely and thorough investigations, and document findings and resolution, while trending issues raised across the facility.

Proactive provides Phase 3 Requirements of Participation assistance including SNF Compliance Program tools, training and resources. Proactive’s Compliance Team also provides ongoing compliance support solutions including oversight of the Compliance and Ethics Program and Interim Compliance Officer service partnerships (click to access the program pdf).

Featured Webinar Download: Moving Mountains Series Phase 3: Implementing an Effective SNF Compliance & Ethics Program

This 1.25-hour webinar recorded download reviews SNF Compliance and Ethics Program requirements effective with phase 3 of the Requirements of Participation on November 28, 2019. This session emphasizes developing or updating the SNF Compliance and Ethics Program to meet all required phase 3 components per the final rule. Webinar details here.

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Blog by Amie Martin, OTR/L, CHC, RAC-CT, VDT-CT, President, Proactive Medical Review

Click here to learn more about Amie and the rest of the Proactive team.