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Compliance is mandatory for SNFs! Is your compliance program survey-ready?

Sign up for MPA's Virtual Compliance Officer Training Course

*** Approved for 5 hours of NAB CEUs***

Compliance is mandatory for SNFs! Is your compliance program survey-ready?

Sign up for MPA's Virtual Compliance Officer Training Course

*** Approved for 5 hours of NAB CEUs***

This blog was published on The Compliance and Ethics Blog on February 1.

I know we all want a Tesla compliance program: state-of-the-art, powered by sophisticated technology, with little maintenance required. We all want the automatic cloud-based software updates that magically appear.

But most of us have a Toyota compliance program: well-built, thoughtful design, with regular maintenance required to ensure reliability. And that’s OK. We just need a good maintenance schedule.

How much compliance upkeep is enough?

Whether you have a Corolla or a Land Cruiser, it’ll last longer, drive better, and be more fun to ride around in if you take care of it.

So what’s the healthcare compliance equivalent of oil changes and air filters? Here are some examples:

• Regular audits of compliance program risk areas
• Policy review and updates
• Ongoing staff training and reminders (not just annual!)
• Quarterly compliance committee meetings and board reports
• Diligent investigation of complaints with documented follow up

Keeping compliance tuned up also means tending to your unfinished business.

What’s your unfinished compliance business? Is there a suggestion box you’ve forgotten to check? A complaint you still need to follow up on? An annual training you couldn’t fit in? A policy you know you need but haven’t had time to put together? These items are your unfinished compliance business. And leaving them unfinished is a little like leaving all of those goldfish crackers under the car seats in the back of your car. This situation will not get better with time.

It’s OK to drive a Corolla.

Like I said earlier, we all want the Tesla. Or the Toyota Land Cruiser. All compliance officers have a wish list miles long of the software they would buy, the staff they would hire, the swag they would order for the best Compliance Week of all time. But most of us are running Corolla compliance programs, and that’s just fine.

If you do the upkeep, a Corolla compliance program can be outstanding. I know plenty of compliance officers running fantastic compliance programs without fancy software and with a $200 (or smaller) compliance week budget (for a small provider). These compliance officers walk the halls every week, talking to employees about compliance and handing out candy bars with their hotline number on them. These compliance officers write thank you notes to employees who come forward with important compliance issues. These compliance officers run some of the best compliance programs I have seen. I’ll take a reliable Corolla compliance program over a Heritage Edition V8 Land Cruiser with third-row seating and allow wheel locks that hasn’t had an oil change in six years.

It’s time to vacuum out the goldfish crackers, remove the Roxette cassette that’s been stuck in the console for three years, and make an ongoing maintenance schedule to keep things running smoothly. After all, it’s the routine maintenance that will make your compliance program a high performer.

Sign up for MPAs compliance training course and learn how to take care of your unfinished compliance business:

Compliance is mandatory for SNFs! Is your compliance program survey-ready?

Sign up for MPA's Virtual Compliance Officer Training Course

*** Approved for 5 hours of NAB CEUs***

With CMS resuming routine nursing home surveys, it’s time to get your compliance and ethics program ready for future surveys.

Whether you are new to compliance or want to make sure you are ready to lead a Phase 3 Compliance and Ethics Program, MPA’s 4-part virtual how-to course can help. Sign up now and receive:

• Four 75-minute classes. We will keep the class going until all your questions are answered!
• One free compliance tool per class
• A 20% discount on MPA’s SNF Compliance Program (save $350)

Sign up for one course, or all four.

Price: $95 per course or $325 for all four. Sign up now.

Those enrolled in all four courses will receive a digital step-by-step compliance program implementation guide.

Can’t attend live? All attendees will receive access to the recorded classes for 6 months.

With CMS resuming routine nursing home surveys, it’s time to get your compliance and ethics program ready for future surveys.

Whether you are new to compliance or want to make sure you are ready to lead a Phase 3 Compliance and Ethics Program, MPA’s 4-part virtual how-to course can help. Sign up now and receive:

• Four 75-minute classes. We will keep the class going until all your questions are answered!
• One free compliance tool per class
• A 20% discount on MPA’s SNF Compliance Program (save $350)

Sign up for one course, or all four.

Price: $95 per course or $325 for all four. Sign up now.

Those enrolled in all four courses will receive a digital step-by-step compliance program implementation guide.

Can’t attend live? All attendees will receive access to the recorded classes for 6 months.

Absolutely.

In July 2019, CMS published a proposed rule that would modify the Compliance and Ethics program aspects of the Phase III Long-Term Care Facilities Requirements for Participation (the “Proposed Rule”).

Some of these proposed modifications removed requirements to assign compliance roles to nursing home personnel. For example, CMS proposes eliminating the following requirements:

• All nursing homes must designate “an appropriate compliance and ethics program contact to which individuals may report suspected violations.”
• Chains of five or more nursing homes must designate a compliance officer for whom the compliance program “is a major responsibility.”
• Chains of five or more nursing homes must designate compliance liaisons at each facility.

If made final, the changes will go into effect one year after the rule goes into effect.

CMS’ proposed removal of the compliance officer, compliance liaison, and compliance reports contact requirements might have some nursing homes jumping for joy. After all, fewer regulatory requirements likely means fewer F-tags on your state survey. While we can likely all agree that fewer F-tags are a good thing, nursing homes would be wise to designate someone as compliance officer.

Keep in mind that the Proposed Rule has not yet been made final, and, as of November 28, 2019, SNFs are expected to comply with the original Phase 3 compliance requirements at 42 CFR 483.85. But, what if the Proposed Rule becomes final?

Maybe.

How many hats does your compliance officer wear? Here are some of the additional roles compliance officers have mentioned to me:

• HR Director
• Administrator/CEO
• Nursing Home Admissions Director
• Training Manager
• Clinical Director or QAPI Director
• Assistant Administrator or VP
• CFO
• Privacy Officer and/or Security Officer
• Director of Nursing
• Marketing/PR Director

Sometimes people just laugh when I ask if they have roles in addition to Compliance Officer – because they have so many.

Give them a break

At the risk of getting some Billboard top ten 1980’s Janet Jackson lyrics stuck in your head for the rest of the day, I’d like to ask you an important question:

What has compliance done for you lately?

Phrased another way:

How has your compliance program helped your organization this year?

Did your hotline encourage employees to report potential false claims internally, so they could be self-reported? Did this hotline call possibly avoid a whistleblower situation?

Did routine compliance audits find a documentation issue – so you could correct it before it became a widespread problem?

Maybe the compliance department collaborated with the HIPAA Security Officer to run a ransomware and phishing campaign, educating employees about potentially hazardous emails and links. As a result, the Compliance Officer and Security Officer received dozens of calls from employees reporting suspicious emails and links that potentially contained ransomware or malware. Can you put a price tag on potentially avoiding a costly ransomware attack?