Oversight, Outbreaks, Overpayments…Oh My!  It seems the LTC industry has no shortage of potential pitfalls knocking at the door. October 24, 2022 has come and gone, with the long-awaited phase 3 surveyor interpretive guidance now in effect for LTC providers. This week’s blog reviews F895 Compliance and Ethics Program (CEP) Requirements and considers the steps to developing a CEP that meets standards and manages risk.

LTC Compliance and Ethics Program Guidance Timeline

      • Beginning in 2000, the OIG provided guidance for 7 essential elements for effective Compliance programs for nursing facilities which are also outlined in the Federal Criminal Sentencing Guidelines. They include: Implementing written policies and procedures and standards of conduct, Designation of a Compliance Officer and Compliance Committee, Conducting effective training, Developing effective lines of communication, Enforcing standards through well-publicized disciplinary guidelines, Conducting internal auditing & monitoring activities, and Responding promptly to detected violations with corrective actions.
      • In 2008, the OIG published supplemental guidance for nursing facilities that provided an expanded listing of potential risk areas for nursing homes to consider as part of their targeted efforts to combat fraud and abuse.
      • Medicare and Medicaid participating facilities were required to implement compliance and ethics programs by Nov. 28, 2019 under the Affordable Care Act (ACA); however, there was no regulatory mechanism to enforce the requirement until the recently updated interpretive guidance which went into effective on October 24, 2022 (Note: In July of 2019, CMS released a proposed rule to remove some of the requirements related to Compliance and Ethics Programs, but that rule was never finalized, so all the Phase 3 requirements are in effect at this time.)

F895 Requirements Effective October 24, 2022

 There are 8 required components of a CEP program listed for F895 at 483.85 (c), including:

      1. Written compliance and ethics Standards, P&P that are reasonably capable of reducing the prospect of criminal, civil and administrative violations and which promote quality of care.
        • Written standards include at a minimum the Designation of an appropriate CE program contact to which individuals may report suspected violations,
        • as well as an alternate method of reporting suspected violations anonymously without fear of retribution
        • and disciplinary standards that set out the consequences for committing violations
      2. Assignment of specific individuals within the high-level personnel of the organization with overall responsibility to oversee the program
      3. Sufficient resources and authority to the Compliance Officer or compliance designee to assure compliance with the standards, P&Ps
      4. Due care not to delegate substantial discretionary authority to individuals who the organization knew or should have known through the exercise of due diligence had a propensity to commit violations
      5. Communication of the standards, policies and procedure to all staff, contractors, and volunteers consistent with their specific roles via training or other means
      6. Steps to achieve compliance with the program policies and procedures, such as auditing and monitoring systems and publicizing the system to anonymously report potential violations
      7. Consistent enforcement of the program standards through disciplinary mechanisms
      8. Appropriately responding to violations and taking steps to prevent further similar violations
      9. And conducting an annual review of the program

In addition, three (3) additional requirements apply for operating organizations with 5 or more facilities, including:

      1. Mandatory annual training – The annual training should be delivered in a practical manner based on the operating organization’s resources, the complexity of the operating organization and its facilities and in accordance with compliance and ethics training requirements at (F946).
      2. Operating organizations that operate five (5) or more facilities must designate a compliance officer for whom the compliance and ethics program is a major responsibility. The operating organization should ensure that the assigned compliance officer has sufficient time and other resources to fulfill all of his or her responsibilities under the operating organization’s compliance and ethics program. The compliance officer should be able to communicate with the governing body without being subject to any coercion or intimidation. This is to ensure that the compliance officer is not unduly influenced by other managers or executive officers, such as the general counsel, chief financial officer or chief operating officer.
      3. A designated compliance liaison must be located at each of the operating organization’s facilities. At a minimum, the facility-based liaison should be responsible for assisting the compliance officer with his or her duties under the operating organization’s program at their individual facilities.


Every LTC facility must now have a Compliance and Ethics Program (CEP) in place. Contact Proactive for assistance in implementing a CEP, training the CEP team or for assistance in managing a compliance-related investigation.  Make plans to join us in November and December 2022 for SNF Compliance Pro Primer, an in-depth webinar series that targets implementing and driving CEP effectiveness. Learn more and register.

Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant

Learn more about the rest of the Proactive team.