Today, CMS issued new and revised
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:
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
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
And, we can review your existing compliance program, or do your annual review. Reply to this email for more information.