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Margaret Scavotto & Scott Gima

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BREAKING NEWS: CMS TO ENFORCE SNF COMPLIANCE IN OCTOBER

Posted by Margaret Scavotto & Scott Gima on 6/29/22 8:09 PM

Today, CMS issued new and revised guidance for long-term care surveyors. This guidance includes the following updates:
  • Clarifications and technical corrections of Phase 2 guidance issued in 2017
  • New guidance for Phase 3 requirements that went into effect November 28, 2019
  • Arbitration requirements and guidance which went into effect September 16, 2019
  • Changes to the Psychosocial Severity Guide
The new guidance for Phase 3 requirements includes the long-awaited F-Tag F895: Compliance and Ethics Programs.
 
In addition to the surveyor guidance, CMS has posted training on the new compliance guidance for surveyors, and the updated State Operations Manual provisions related to F895 (Appendix PP). Here’s what you need to know:
 

ENFORCEMENT

CMS will begin reviewing nursing home Compliance and Ethics programs via survey on October 24, 2022.
 

WHAT ABOUT THE PROPOSED RULE?

The State Operations Manual uses the original Compliance and Ethics Programs rule that was issued as part of Phase 3 – not the proposed rule. Nursing homes should make sure their compliance programs are built to the original rule (plus OIG guidance). MPA has summarized the requirements for you below.
 

NURSING HOME COMPLIANCE REQUIREMENTS

All nursing homes must have the following:
  • Written compliance and ethics policies and procedures that:
    • Reduce the risk of criminal, civil and administrative violations
    • Promote quality of care
    • Designate a compliance contact to receive reports
    • Include an anonymous way to report non-compliance without retribution
    • Include disciplinary standards
    • Apply to contractors and volunteers
  • Policies and procedures communicated to all staff, contractors, and volunteers
  • Assigned high-level personnel oversight for the compliance program, and sufficient resources and authority for such high-level personnel
  • Due care not to delegate substantial discretionary authority to individuals the SNF knew or should have known had a propensity to commit a crime
  • Auditing and monitoring
  • A reporting system
  • Consistent enforcement via discipline
  • Annual review. 
Organizations with five or more facilities must also have:
  • A mandatory annual compliance training program, and
  • A compliance officer who reports directly to the governing body, with designated compliance liaisons at each site
(For a comprehensive list of requirements, please see 42 CFR 483.85).
 

WHAT ELSE IS IN THE GUIDANCE?

The CMS guidance also addresses other Phase 2 and Phase 3 provisions of the long-term care regulations. You can read the other changes here
 

IF YOU NEED HELP

MPA is ready to help you meet these compliance and ethics requirements, MPA has nursing home compliance programs available for download on our store.
 
And, we can review your existing compliance program, or do your annual review. Reply to this email for more information.

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Topics: Penalties and Enforcement, Affordable Care Act, compliance, surveys

Cold hard HIPAA stats

Posted by Margaret Scavotto & Scott Gima on 1/25/22 8:15 AM

As we enter a new year, it’s a good time to review the status of data breaches, HIPAA hazards, and the state of security risk with some statistics:

  • The average cost of a data breach in the United States is $9.05 million. The average cost is higher in organizations with greater compliance failures.

  • Only 25% of employees are “very confident” they can identify a social engineering attack.

  • 76% of healthcare employees have received security awareness training. That means 24% have not.

  • 24% of employees believe “clicking on a suspicious link or attachment in an email represents little or no risk.”

  • Only 31% of employees think “allowing family members of friends to use work devices for personal activities outside of work” is risky.

  • In the past 12 months, 94% of organizations have had an insider data breach. The most common cause is human error.
  • As many as 90% of data breaches are phishing attacks

It is always eye-opening to review the latest HIPAA stats – because they get colder and harder every year. Especially in healthcare.

What you can do

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Topics: HIPAA, data breach, security

When HIPAA security is a public health issue

Posted by Margaret Scavotto & Scott Gima on 1/18/22 9:00 AM

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Topics: HIPAA, data breach, security, compliance, webinar

CMS & OSHA Vaccine Rules Are Here!

Posted by Margaret Scavotto & Scott Gima on 11/11/21 11:07 AM

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Topics: guidance, compliance, COVID-19

Free Webinar: HIPAA Security - Board of Governance Responsibility

Posted by Margaret Scavotto & Scott Gima on 9/3/20 10:32 AM

Join HIPAAtrek and MPA's Executive VP Scott Gima for a complimentary webinar:

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Topics: HIPAA, security, webinar

Download MPA's HIPAA, COVID-19 & Social Media Roadmap

Posted by Margaret Scavotto & Scott Gima on 7/8/20 8:38 AM

The rise of social media has revolutionized the way people connect. In the health care workplace, social media also brings countless opportunities for employees to violate HIPAA. Balancing this new landscape of increased sharing through technology and unchanged patient privacy rights is a minefield for healthcare providers.

Without education and policies from their employers, health care employees can easily get into trouble, quickly putting their employers at risk for HIPAA penalties, lawsuits, and devastating PR consequences. The pandemic has only exacerbated the privacy challenges associated with social media. MPA’s HIPAA, Social Media & COVID-19 Roadmap tells you what you need to know about this challenge, and what you can do about it.

Taking on the unstoppable world of social media might seem impossible. But it's better to help employees use it properly--and know when they aren't - than to do nothing and wait to hear it from the patients (or the media).

Click here to download.

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Topics: HIPAA, COVID-19

Know your risk: HIPAA breach stats

Posted by Margaret Scavotto & Scott Gima on 2/6/20 8:15 AM

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Topics: HIPAA, security, breach notification

CMS Changes SNF Compliance Program Requirements – Again

Posted by Margaret Scavotto & Scott Gima on 9/10/19 7:13 AM

Ladies and gentlemen, long-anticipated compliance program requirements are changing, one more time. Let’s take a look at what has changed – and what hasn’t.

The proposed rule

On July 16, 2019, CMS published a proposed rule that would modify multiple aspects of Phase III of the Long-Term Care Facilities Requirements for Participation (the “Proposed Rule”). The goal of the Proposed Rule is to reduce regulatory burdens and costs, allowing nursing homes to focus resources on providing quality resident care. Some of the most discussed proposed amendments are those to the Compliance and Ethics Program requirements (42 CFR 483.85), which, if finalized, will become effective one year later. With comments from the public due September 16, 2019, our best guess is that enforcement will begin October or November 2020.

Good news: fewer compliance-related F-tags ahead

Nursing homes: LeadingAge (and other associations) successfully lobbied on your behalf. 

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Topics: Affordable Care Act, OIG compliance resources, skilled nursing, compliance

Why Compliance Should Care About the War on Opioids

Posted by Margaret Scavotto & Scott Gima on 6/18/19 8:51 AM

We have an opioid problem

In the United States, 134 opioid-related deaths occur daily. In 2016, more than 60,000 Americans died from drug overdoses, and two-thirds of those deaths were opioid related. Fentanyl is now responsible for more overdose deaths (28.8%) than heroin. And, three out of four new heroin users first misuse prescription opioids.

In 2017, almost one-third of Medicare Part D beneficiaries received opioids. About 460,000 beneficiaries received high amounts of opioids; 71,000 beneficiaries were at serious risk of misuse or overdose; and almost 300 prescribers had questionable prescribing. Everyone agrees our country has an opioid problem.

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Topics: Quality Assurance, Excluded Providers, Opioids, compliance

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