Element #1-Corporate Compliance Officer/Designee

I call myself a “nursing home brat.” As a third generation nursing home provider I worked alongside my grandparents and parents and have been part of the evolution of long- term care. As an industry, we have significantly grown and matured- having a better understanding of the needs of our elders and quality of care. Along with many positive changes, such as physical restraint elimination and reduction in psychoactive medications, comes more and more regulations and oversight. How can providers become proactive versus reactive? I believe a key component is knowing, truly knowing what’s happening in your facility.

Coming in 2019 as part of the RoP, is a requirement for Mandatory Corporate Compliance. While it might feel like another burdensome regulation, it can actually be a functional tool to objectively learn about your operation. There are 7 key components to a compliance program as discussed by the OIG which I will lend some insight in a series of blogs : (https://oig.hhs.gov/authorities/docs/cpgnf.pdf)

1. Corporate Compliance Officer/Designee

2. Compliance Policy and Procedures

3. Effective Lines of Communication

4. Training and Education

5. Enforcement and Discipline

6. Monitoring and Internal Audit Systems

7. Response to Problem and Corrective Actions

For those providers just starting a Compliance Program, a key feature is transparency. What does this mean? The government is expecting that there is transparency in your operation. That means no more saying “but I didn’t know.” We are required to create systems and educate our staff – at every level- to develop a series of checks and balances. This is not done overnight or with a checklist or binder but rather through change management. These series of posts will assist you in implementing a compliance program within your organization.

1) Compliance Officer (CCO) and Compliance Committee

First step is having the right leader. When choosing a compliance officer, you want to be sure she is well respected in the organization and has “the ear of ownership”. Your corporate compliance officer sets the compliance tone in the organization and must be highly visible. She is your compliance mascot who will be building your program including assessing your policy and procedures, building robust training program and providing open, anonymous lines of communication. She will be responsible for holding staff and ownership accountable to facility code of conduct.

The Corporate Compliance Officer will work with the compliance committee to build robust internal audit systems to self-monitor and self-correct. Depending on the size of your organization, you may have CCO designees in your buildings. These systems need to be repeatable – not based on a person but based on a process. A challenge for the compliance officer, especially in a multi facility organization, is the many areas of risk that need to be assessed. At a minimum, the OIG recommends including quality of care and residents rights, vendor relationships, billing and cost reporting and record keeping and documentation.

Who should be on the compliance committee? This is very specific to your organization and the structure of your compliance program. I like to see a diverse group who can help paint a complete picture of the facility. It’s amazing what you learn from you night shift CNA or your cook. Be sure to include a representative from admissions, billing and marketing in your committee. You want to empower this group to speak freely and impress upon them the importance of their role.

For the compliance officer to be effective and successful there needs to be full support from leadership and access to information. The compliance officer needs to have a clear top view of the organization and an ability to drill down. She needs to collect information across business/risk areas so she can deliver accurate, valid information.

Question to ask yourself:

1) Is there a “true” culture of compliance coming from leadership and not just a check mark next to the compliance category?

2) Does the compliance officer have access to data across the organization so she can ask the right questions?

3) Is leadership available to compliance officer and is compliance officer providing proactive, data based information to the leadership?

4) Do staff members know the role of your compliance officer and is she visible and respected within the organization?

The next step is developing policy and procedures for you compliance program- stay tuned!