Revised long term care surveyor guidance for F895 Compliance and Ethics Programs was released June 29, 2022. CMS will begin enforcing F895 on October 24, 2022 and has released specific surveyor guidance and updates to Appendix PP to guide preparations.

Effective compliance and ethics programs need to accomplish three primary goals

      • Prevent, detect, and correct illegal or non-compliant behavior
      • Ensure the highest standards of quality care, and
      • Meet the required components specified in F895 at §483.85 (c)

F895 at §483.85 (c) clarifies the Phase 3 requirements of participation for compliance and ethics programs including:

      • Written compliance and ethics standards, policies, and procedures including, but not limited to the designation of a program contact, anonymous reporting systems, and disciplinary standards,
      • Designation of oversight responsibility for the program by high-level personnel such as the board of directors with sufficient resources and authority designated to the program
      • Due care not to delegate substantial discretionary authority to those with a propensity to engage in criminal, civil and administrative violations under the Social Security Act
      • A strategy to effectively communicate program standards, policies and procedures to employees, volunteers and contractors. In addition, training requirements are included at §483.95(f)
      • Effective systems to achieve compliance, such as auditing and monitoring targeting detection of potential violations, reporting systems and processes that ensure data integrity
      • Consistent enforcement of standards, policies and procedures, including but not limited to disciplinary actions for failing to detect and/or report violations
      • Appropriate responsive actions are taken following a violation to prevent further similar violations in the future, including updates to the program as necessary
      • For organizations with five or more facilities, additional components are required, including:  mandatory annual training on the compliance and ethics program, a designated compliance officer, designated compliance liaisons located at each facility, and an annual review of the program.

Questions to consider as you evaluate your program readiness:

      1. Is there a written program manual that clearly guides program efforts in reducing the possibility of compliance violations?
      2. How well does your program identify specific risks and determine resource needs based on the facility assessment (483.70(e)?
      3. Have requirements related to communication of the program and training been met?
      4. Will staff, when interviewed, report that they are aware of the program, how to report and that they are confident they could report a compliance concern without fear of retribution?
      5. Is there a mechanism to allow anonymous reporting?
      6. How effectively are auditing and monitoring systems used to detect potential violations?
      7. Can you justify that reasonable steps were taken in response to a detected violation and that those measures were taken in a timely manner?
      8. Is the program effectively assessed annually and are updates made as needed in response to substantiated violations, regulatory or other changes?

Make plans to join us beginning November 3, 2022, for a 6-part webinar series devoted to improving compliance and ethics programs in SNF, LTC, and AL settings. This series will consider the newly released interpretive guidance and provide key insights to drive a robust compliance and ethics program. Learn more and register. You may also contact Proactive for expert assistance in developing or updating your compliance and ethics program, or for guidance in managing compliance investigations.


Amie Martin, OTR/L, CHC, RAC-CT, MJ

Learn more about the rest of the Proactive team.