Delay for one year the SNF Compliance and Ethics Program requirements

While CMS published a proposed rule to delay for one year the SNF Compliance and Ethics Program requirements, providers have good reason to move forward in implementing the Compliance and Ethics Program with the original phase 3 target date of November 28, 2019. (1) The proposed rule remains “proposed” and has not been finalized. (2) Compliance programs help to solidify strong processes for reducing, detecting, and correcting wrongdoing in the facility.

3 Primary Goals of Compliance & Ethics Programs

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.

Where do I begin to develop or refresh the Compliance & Ethics Program in my facility?

1) Understand the seven core elements that should be implemented to deem a compliance program effective and review the OIG guidance on compliance programs for nursing facilities.

2) Develop written compliance and ethics standards, policies, and procedures and updated them periodically.

3) Designate a Compliance Officer or Designee and establish a Compliance Committee. The Compliance Officer’s role should be separate from operations when possible, and include thoughtful lines of authority to allow for some level of independence in managing the program. The Compliance Officer/designee should have the overall responsibility of overseeing compliance in the facility and 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.

4) 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).

5) 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. Allow for anonymous reporting of suspected violations in your plan.

6) 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. Determine priorities by conducting a facility risk assessment. 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.

7) 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 and their resolution. Investigations of potential violations should be initiated based on the assigned priority level and corresponding response timeframe. Review violation reports and investigation outcomes periodically with the Compliance Committee and include information on trends and any major concerns during reports to the board.

8) 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.

9) Periodic Review. A compliance program is never finished; it should always be a work in progress. Periodic reviews for program effectiveness should be conducted –the phase 3 requirements state at least annually, while the proposed rule which potentially pushes back the effective date for Compliance & Ethics programs being required does not mandate a specific review timeframe.

Proactive has the SNF Compliance & Ethics Program policies, tools, and resources you need to jump start your program without reinventing the wheel. Contact us today to develop a program or to request a review of an existing program to fill any gaps.

Learn more about Proactive’s Compliance Program Implementation Partnerships.

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

This 1.25-hour webinar reviews SNF Compliance and Ethics Program requirements effective with phase 3 of the Requirements of Participation on November 28, 2019. Click here to learn more about this product in our shop.

Webinar: Phase 3 Requirements of Participation Nitty Gritty: What Needs to be Done by Nov.28

This 60 minute on-demand webinar session will provide clarification on what facilities must do to prepare this year and what can wait.Click here to learn more about this product in our shop.

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

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