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Reopening your compliance program in a pandemic

Posted by Margaret Scavotto, JD, CHC on 6/23/20 10:15 AM

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pandemic continues

Here in Missouri, much of the state reopened on June 15: pools, restaurants, and gyms included. But life looks a lot different. Visitors are still restricted at nursing homes, people are wearing masks, hand sanitizer lurks around every corner, and many people are still choosing to stay home and use curbside services. It’s a different world.

Throughout the pandemic, I have asked healthcare providers: How has COVID-19 affected your compliance and HIPAA programs?

  • Some people say: “It’s business as usual.”
  • Others say: “I’m still working on compliance but at a much slower pace.” This is understandable, given the number of COVID-related tasks and guidance added to compliance officers’ plates.
  • A few people have told me they actually have MORE time to work on compliance now, because other projects have been put on hold.
  • And a handful have told me that compliance has been put on hold completely during the pandemic. I understand why this happens and I empathize with it. These are unprecedented times and healthcare providers are in the middle of a centennial challenge.

If you have had to curtail or limit your compliance efforts due to COVID-19: Document your decisions. Document what activities have been delayed, and why (e.g., resources were redirected to infection control).

As we enter month four of the national public health emergency, my hope for compliance officers who have slowed (or stopped) compliance efforts that they find a way to keep their compliance programs going and, to the extent possible, get back to business as usual.

Where should we start?

How you resume compliance will depend on your risks and resources. Here are some ideas to consider:

  • Schedule a quarterly compliance committee meeting (especially if you are overdue). Use this time to recap your organization’s risks – COVID and non-COVID – and prioritize.
  • Create an action plan to address these risks in order of priority. Decide how you will tackle each risk. Map out your plan over 12 months – and follow up monthly or quarterly to check on progress.
  • Update your board. It’s possible that board meetings have been filled with urgent COVID-19 issues. If compliance has been bumped from the agenda, it’s time to get back on. Compliance, after all, has a key role in addressing and mitigating COVID-19 risks, like HIPAA, infection control, and EMTALA.
  • Find out how you can support your staff. Healthcare employees are likely exhausted, overwhelmed, and stressed out. Compliance can help. An unprecedented amount of guidance has been published since February. What information could your employees be struggling with? Do they need help understanding new HIPAA guidance during the pandemic? When is the last time your employees were reminded of how to report compliance issues? When is the last time the Compliance Officer walked the floors to talk with staff, encouraging them to raise questions?
  • Nursing homes should work on Phase 3 Compliance and Ethics programs. This means making sure updated policies are in place, policies are disseminated, and an annual review is conducted. It can take several months to conduct an annual review – start now and move the process forward. When surveys resume, you will be better off if you aren’t scrambling to implement compliance.

Yes, the pandemic continues. But compliance should also continue. When COVID-19 passes, or at least subsides to a better “new normal,” your organization will need compliance. Compliance provides education that helps people do their jobs; risk management and strategy to make your organization better; and process improvement to provide the best care possible. By taking little steps now to keep compliance going, you can avoid starting over after the pandemic.

MCS Signature November 2018


Topics: Compliance Basics, COVID-19

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