Harmony Healthcare Blog

Developing an Effective Compliance Program: Policies and Procedures

Posted by Joyce Sadewicz on Fri, Apr 07, 2017

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Policy-and-Procedures-721774-edited.jpgThe Requirements of Participation require a Compliance and Ethics program to be implemented in each facility in Phase 3 by November 28, 2019.  While this appears to be a long time to prepare, it takes many months to develop and implement an effective compliance program.  One of the foundations of an effective compliance program is Policies and Procedures including Standards and a Code of Conduct or Corporate Philosophy.  The Standards or Code of Conduct should state the company’s commitment to compliance with federal and state standards, express the company’s goals, mission, values and ethical requirements, and the expectations that all staff, including management and the governing board, comply with the standards.  

One of the first steps in the process is to review, modify, and update the existing policies and procedures and develop new policies and procedures to comply with other components of the Requirements of Participation.  

The entire process of developing a program is based on a Quality Assurance, Performance Improvement method, essentially the “Plan, Study, Do, Act process”.  Plan what policies and procedures are needed, update previous policies, develop new policies, implement the policies, and re-assess if the policies and procedures are effective and modify as needed. 

Some policies that may require development include: 

  • Claim development and submission including MDS and MMQ completion and submission.  The procedures for MDS and MMQ completion and development should be developed first to outline the basis for payment and claim development.  These procedures will vary from facility to facility and should be specific to each facility.  This is also an excellent place to start as the team is very familiar with these procedures but likely have not documented them.  The MDS 3.0 RAI process and MMQ completion lead to the next policy and procedure for Care Plan development.  
  • Comprehensive Care Plan
  • Medicare Medical Necessity definitions and documentation as well as rules for other payers.
  • Anti-kickback and self-referral.
  • Free goods and
  • Service contracts.
  • Resident Safety including resident interactions, staff screening, sufficient staffing, medication management, appropriate use of psychotropic medication, abuse and neglect.
  • Rehabilitation Services including clinically appropriate levels of Therapy delivery, medical necessity for Therapy services, complete and comprehensive documentation of services rendered, periodic reconciliation of physician orders and treatment provided and review of physician certification of Medicare Part A and Medicare Part B services.
  • Restorative and Personal Care Services to allow residents to attain and maintain their highest level of mental, physical and psychosocial functioning.  This will include the prevention of pressure ulcers, range of motion programs, fall prevention, ambulation, incontinence management and bathing, dressing and grooming skills.
  • Physician Services including oversight, referral patterns, and physician self-referral.
  • Hospice Services including eligibility criteria and election of hospice benefits.
  • HIPAA Privacy and Security Rules.
  • Non-Retaliatory policy for reporting of suspected misconduct.
  • Development and implementation of a Medical Records Process that secures complete and accurate Medical Record Documentation including services records/logs, retention and destruction of records, and privacy of records.
  • Vendor Agreements


This list is not finite and many policies and procedures may already exist.  If policies have already been created, it is recommended that they be reviewed with the new Requirements of Participation in mind.  The list of policies is ever expanding to meet the needs and changes in the long term and SNF industry including Bundled Payments, Quality Reporting, and Value-Based Purchasing.  This appears to be an overwhelming and mind boggling task.  As with any process, begin with the basics and work through to the most difficult. 

Harmony Healthcare International (HHI) is available to assist with policy and procedure review and development, you can contact us by clicking here.  Also, join us in person for our upcoming Compliance Certification Courses (CHHi-CP).  Click here to see the dates and locations.

Join us November 2nd & 3rd, 2017 at Foxwoods Resort for harmony17
6th Annual LTPAC Symposium
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harmony17 long-term care symposium

Tags: Compliance

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