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2019 Is the Year of the Compliance Program Annual Review

Posted by Margaret Scavotto, JD, CHC on 5/15/19 12:17 PM

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All skilled nursing facilities will be required to have conducted an annual review of their compliance programs by November 28, 2019 (and it’s essential for other providers, too).  SNFs who have not conducted an annual review by November 28, 2019 will be in violation of the law.  


What’s an annual review?

“Annual Review,” “Compliance Program Assessment,” and “Compliance Program Effectiveness Review” all mean the same thing: a comprehensive, well-documented evaluation of the compliance program. The review assesses each element of compliance and each risk area, identifies gaps, and includes a plan of action to close those gaps.

The OIG has recommended compliance review for years

In its Compliance Program Guidance documents, the OIG consistently recommends that providers evaluate their compliance programs in order to identify improvements and keep the programs effective. For example, the OIG Compliance Program Guidance for Nursing Facilities states:

 ...the OIG recommends that all nursing facilities evaluate their current compliance policies and procedures by conducting a baseline assessment of risk areas, as well as subsequent reevaluations…  


How a nursing facility assesses its compliance program performance is therefore integral to its  success. The attributes of each individual element of a compliance program must be evaluated in order to assess the program’s ‘‘effectiveness’’ as a whole. Examining the comprehensiveness of policies and procedures implemented to satisfy these elements is merely the first step. Evaluating how a compliance program performs during the provider’s day-to-day operations becomes the critical indicator.  

The Federal Sentencing Guidance expect compliance reviews, too

Likewise, the Federal Sentencing Guidelines, which are used by the United States federal courts to sentence individuals and organizations, include an expectation that organizations conduct periodic reviews of their compliance programs:

2(a)(5) The organization shall take reasonable steps— (… (B) to evaluate periodically the effectiveness of the organization’s compliance and ethics program 

In other words, while the compliance program reviews will soon be required by law for nursing homes – they have long been expected by the federal government for all health care providers.

Are you ready for November?

annual reveiw june 30

It can take several weeks or even months to conduct a compliance program review. Iif this is your first experience with a compliance review, leave yourself plenty of time.

The Annual Review is not just mandatory. It’s essential to moving compliance forward for your organization. It gives your board or CEO a yardstick by which to measure the compliance programs they oversee. It gives compliance officers a list of successes to celebrate and challenges to overcome in the coming year.

MCS Signature November 2018

Topics: Compliance Basics, Affordable Care Act, annual review, skilled nursing

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