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Nursing home compliance programs: What is happening with surveys?

Posted by Margaret Scavotto, JD, CHC on 1/28/21 10:40 AM

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Nursing homes have been through a lot in the past pandemic-year (to put it mildly). Possibly more than any other category of organizations. The constant changes in surveys have not made this easier:

  • In March 2020, CMS temporarily suspended routine nursing home surveys due to COVID-19, in order to focus on infection control and Immediate Jeopardy issues.
  • In August 2020, CMS announced that it would resume onsite surveys, and expand desk reviews. 
  • In December 2020, we learned that the pandemic has created significant state survey backlogs. 

What’s next?

The OIG recommended that backlogged surveys be completed. And we know infection control is still a top concern – but that the comprehensive survey process is also back. We also know that – at some point in the future – Compliance and Ethics programs will be part of the nursing home survey process. We are still waiting on a final rule and surveyor guidance addressing these Compliance and Ethics programs – but the fact is, at the present moment, compliance programs are mandatory for nursing homes and will become part of the survey process.

Many nursing homes put compliance on hold – understandably - when COVID-19 hit. If your organization is not ready to be surveyed on compliance, now is the time to get ready. Here is what you need:

  • Written standards, policies and procedures
  • Assignment of responsibility to high-level personnel
  • Sufficient resources and authority
  • Due care not to delegate to those with a propensity to commit crimes
  • Policy communication to staff, contractors and volunteers
  • Auditing and monitoring
  • Reporting system
  • Disciplinary enforcement
  • Corrective action
  • Annual review

Chains of 5+ SNFs also need:

  • Mandatory annual compliance training
  • Compliance officer who reports to the governing body
  • Compliance liaisons at each facility

While these requirements could change with the issuance of the Final Rule and surveyor guidance, MPA recommends building your program to meet these guidelines plus OIG guidance – and adjusting your program if and when changes are made.

MPA can help

MPA has SNF compliance programs available for purchase and download on our store. They meet current Phase 3 requirements, and they come with 12 months of updates – if requirements change, MPA updates the program for you at no additional charge. MPA can also conduct your annual review.

Get your compliance program ready for survey with MPA's Training E-Course:

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Topics: compliance, Phase 3, surveys

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