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Are You Prepared for New Compliance Program Regulations?

January 14, 2019
Compliance By LW Consulting Inc.

New regulations for compliance programs go into effect on November 28, 2019. On this date, survey agencies will be authorized to issue survey deficiencies under F-Tag F895. If it's been a while since you've updated your compliance program, then it is likely that it concentrates on preventing and detecting billing and documentation errors and not quality of care. State and federal agencies are urging providers to review their existing compliance program. Are you prepared for the new compliance program regulations?



Components of an Effective Compliance Program

As per the Code of Federal Regulations (42 CFR 483.85 - Compliance and Ethics Program), every facility's compliance program has to contain the following primary components. 

1. Written Compliance and Ethics Standards, Policies, and Procedures

A compliance program must have “written compliance and ethics standards, policies and procedures that are reasonably capable of reducing the prospect  of criminal, civil and administrative violations.”  These written standards, policies and procedures must also promote quality of care. In addition, facilities must designate a compliance contact to which staff may report suspected violations anonymously. 

2. Assignment of Specific, High-Level, Personnel to Oversee the Compliance Program

This individual can be, but is not limited to, the Chief Executive Officer (CEO), members of the board of directors, or other directors within the operating organization. 

3. Sufficient Resources and Authority

The individual(s) assigned to oversee the compliance program should have sufficient resources and authority to “assure compliance with such standards, policies and procedures.”

4. Due Care Not to Delegate Substantial Discretionary Authority

Organizations should take due care  not to delegate authority to individuals they “knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations under the Social Security Act.”

5. Effective Communication

The compliance program should include effective communication of standards, policies, and procedures for staff, individuals providing contract services, and volunteers. Requirements include, but are not limited to, mandatory training, orientation programs and the dissemination of information that explains the compliance program requirements.

6. Monitoring and Auditing Systems

Reasonable steps should be taken to audit and monitor systems designed to detect criminal, civil, and administrative violations under the Social Security Act by the operating organization's staff, individuals providing contractual services, or volunteers. In addition, systems need to be in place for the anonymous reporting of violations without fear of retribution.

7. Consistent Enforcement of Standards, Policies and Procedures

All policies and procedures should be enforced, and appropriate disciplinary actions, as appropriate, should be implemented for failure to detect and report a violation to the compliance program contact.

8. Response and Remediation

After a violation is detected, all reasonable steps must be taken to respond appropriately to the violation and prevent further similar violations. This includes any necessary modification to the compliance program to prevent and detect criminal, civil, and administrative violations under the Social Security Act.

Additional Components for Operating Organizations with Five or More Facilities

In addition to the above mentioned eight components, operating organizations must include the following three additional components:

1. Mandatory Annual Training
2. A Designated Compliance Officer
3. Designated Compliance Liaisons

Developing and Implementing Your Compliance Program

The end goal is to have a successful compliance program that can be assessed by surveyors. A facility's compliance program must contain the above listed components and the three supplemental components if the facility is an operating organization.

LW Consulting, Inc. can help review your facility's current compliance program and develop a plan to improve future compliance. We can also assess your current systems to develop a compliance plan if there isn't one already intact. 



In a press release identified through McKnight's Long-Term Care News on July 16, 2019, CMS may be delaying implementation of several segments of the Phase III implementation previously scheduled to be rolled out in November 2019. According to the article, Quality Assurance Process Improvement plan and Compliance and Ethics related requirements may be delayed until November 2020.

Comments will be collected by CMS until September 16, 2019 prior to a final decision being implemented. 

You can access the McKnight's article here.

Also, additional information on the proposed and final rules can be accessed here by viewing the CMS blog. 

Opportunities to post comments, up to September 16, 2019, can be viewed here.


Are you prepared for new compliance program regulations? Contact the experts at LW Consulting, Inc.

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