Breaking Compliance News Blog


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:


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


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.


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).


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


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

Nursing home compliance programs: What is happening with surveys?

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


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


Posted by Margaret Scavotto, JD, CHC on 8/18/20 11:52 AM

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):

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Topics: annual review, guidance, compliance, Phase 3, surveys

Have you measured your compliance culture?

Posted by Margaret Scavotto, JD, CHC on 2/19/20 11:00 AM


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.

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Topics: Culture of Compliance, annual review, compliance, Phase 3, surveys

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