Breaking Compliance News Blog

• 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

ENFORCEMENT

WHAT ABOUT THE PROPOSED RULE?

NURSING HOME COMPLIANCE REQUIREMENTS

IF YOU NEED HELP

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:

In March, CMS announced that it was suspending routine surveys for nursing homes during the pandemic, in order to focus on infection control and Immediate Jeopardy issues. However, CMS announced on Monday that this suspension is coming to an end.

In its memo to State Survey Agency Directors, titled: Enforcement Cases Held during the Prioritization Period and Revised Survey Prioritization, CMS announced that it is resuming onsite revisits and other surveys, and expanding its desk review.

In addition to the expanded surveys previously authorized for states entering Phase 3 of the Nursing Homes Reopening guidance, CMS is authorizing further survey expansion. The guidance states (direct quote):

Many healthcare providers are accustomed to assessing their compliance programs on a regular basis. The OIG recommends this practice annually - and, as of November 28, 2019, nursing homes are required to conduct an annual review. It is common for providers to evaluate compliance policies, training, auditing programs, and other aspects of the seven elements of an effective compliance program. It is less common - and yet crucial - for organizations to evaluate their compliance culture.