Breaking Compliance News Blog

Sign up for MPA's May Compliance & COVID-19 Webinars

Posted by Margaret Scavotto, JD, CHC on 5/4/20 10:12 AM

I hope you can join me for MPA's upcoming complimentary webinars:

For all providers:

Keeping Compliant During COVID-19

May 19, 2020, 12 CST

Register

 

For nursing homes:

Phase 3 Compliance Webinar: Social Media Compliance During a Pandemic

May 27, 2020, 12 CST

Register now

 

Zoom will email you a link to access the webinar - and I will also send this link around the day before the webinar.

Have a great day!

COVID-19 Discounts:

  • All digital download HIPAA Tool Kits are 50% off until June.
  • Compliance program annual reviews are 25% off until June (call or email me for info)
  • Our HIPAA & COVID-19 Toolkit is available at the discounted price of $95.
  • MPA will continue putting out HIPAA announcements, news, and tips on the blog
  • MPA has free compliance and HIPAA resources on its Free Resources page.  

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Topics: compliance, Phase 3, COVID-19

Phase III: Do SNFs need a Compliance Officer?

Posted by Margaret Scavotto, JD, CHC on 2/25/20 8:15 AM

 

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?

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Topics: compliance, compliance officer, Phase 3

Have you measured your compliance culture?

Posted by Margaret Scavotto, JD, CHC on 2/19/20 11:00 AM

 

Many healthcare providers are accustomed to assessing their compliance programs on a regular basis. The OIG recommends this practice annually - and, as of November 28, 2019, nursing homes are required to conduct an annual review. It is common for providers to evaluate compliance policies, training, auditing programs, and other aspects of the seven elements of an effective compliance program. It is less common - and yet crucial - for organizations to evaluate their compliance culture.

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Topics: Culture of Compliance, annual review, compliance, Phase 3, surveys

Download MPA's Guide to Compliance Program Review/Annual Review

Posted by Margaret Scavotto, JD, CHC on 2/12/20 9:15 AM

Compliance program review is essential to maintaining an effective program.

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Topics: annual review, compliance, Phase 3

Top 5 reasons you need a compliance program review

Posted by Margaret Scavotto, JD, CHC on 2/11/20 10:15 AM

 

1. Without a review, you don’t know what you don’t know.

Were policies distributed? Were staff, board members, contractors, and volunteers properly trained? Were all risk areas audited? Were audit findings mitigated? Were compliance reports properly investigated and met with discipline and corrective action? Without conducting a review, you don’t know. Who would you rather identify your compliance flaws: your own organization, via a compliance review – or the government, via an audit or investigation?

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Topics: Compliance Basics, annual review, compliance, vendor screening, Phase 3

Phase III: Do SNFs need to conduct a compliance program annual review?

Posted by Margaret Scavotto, JD, CHC on 1/21/20 8:00 AM

In a word: yes.

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.

One of the proposed modifications brought a sigh of relief from the nursing home industry: CMS wants to drop the requirement that nursing homes conduct an annual review of their compliance programs.

Instead, CMS proposes the following: “The operating organization for each facility must periodically review and revise its compliance program to identify necessary changes within the organization and its facilities.”

While CMS did not define “periodically” in the proposed rule, CMS refers to a “biennial” review in the proposed rule comments. Hopefully this will be clarified in the final rule.

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?

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Topics: annual review, compliance, Phase 3

Quiz: Is your nursing home ready for Phase 3 compliance?

Posted by Margaret Scavotto, JD, CHC on 1/7/20 8:15 AM

As of November 28, 2019, nursing homes are expected to be in compliance with the Phase 3 compliance regulations.

On November 22, 2019, CMS issued a memorandum with an update on the Phase 3 Requirements of Participation. In this memo, CMS advised:

  • CMS will not release updated Interpretive Guidance and training addressing Phase 3 until the second quarter of 2020. CMS is somewhat limited in its ability to survey until then.
  • But... nursing homes are still expected to comply with Phase 3 by November 28, 2019.

What does this mean?

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Topics: compliance, Phase 3

Phase 3 Nursing Home Compliance Update!

Posted by Margaret Scavotto, JD, CHC on 12/4/19 10:58 AM

On November 22, 2019, CMS issued a memorandum with an update on the Phase 3 Requirements of Participation. In this memo, CMS advised:

  • CMS will not release updated Interpretive Guidance and training addressing Phase 3 until the second quarter of 2020. CMS is somewhat limited in its ability to survey until then.
  • But... nursing homes are still expected to comply with Phase 3 by November 28, 2019.

What does this mean??

It means that, right now, nursing homes are required by law to comply with Phase 3, including the Compliance and Ethics Program requirements - and CMS expects nursing homes to be in compliance.

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Topics: skilled nursing, guidance, compliance, Phase 3

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