The Long Term Care industry, one of the most regulated industries, is now facing discriminating enforcement concerning business and financial practices. Skilled Nursing Facilities (SNFs) must be aware of the risk for non-compliance with the requirements arising from the Affordable Care Act (ACA) of 2010. Of particular significance to facility administrators, the ACA declared March 23, 2013, as the deadline by which skilled nursing facilities must adopt an effective compliance program.
Compliance is every Administrator’s responsibility. Administrators in long term care now, more than ever, need to understand the role of a Compliance Officer and appoint a professional who understands the complexities of the long term care industry. This person must be knowledgeable of billing practices, MDS 3.0 regulations, Medicare and Medicaid regulations and Rehabilitation services. Harmony (HHI) recommends that the individual appointed to this role be actively involved in a professional organization, such as the Health Care Compliance Association (HCCA). In addition, this individual should be involved in any compliance reviews conducted at the facility.
The goal of the compliance program is to identify and prevent unethical or potentially criminal behavior by your employees or other individuals associated with your facility. Much like Quality Assurance and Performance Improvement (QAPI), this program will coordinate audits, provide resolution to concerns, and identify activities that require reporting related to business and financial claims or practices.
Most facilities will wonder where to start. Comprehensive chart reviews, action plans for follow up, and an in depth knowledge of regulations is imperative. The following is offered for guidance:
- Establish compliance standards and procedures to reduce the likelihood of violations and promote quality of care
- Designate a high-level individual with overall responsibility to oversee compliance with sufficient resources and authority to enforce compliance standards
- Avoid delegating substantial discretionary authority to individuals that have the potential to engage in violations
- Communicate facility compliance standards and procedures to all employees
- Establish monitoring and auditing systems designed to detect violations
- Initiate a procedure for employees to report violations without fear of retribution
- Enforce compliance standards through appropriate disciplinary actions
- Establish a procedure for responding to any violation to prevent reoccurrence of the violation
- Reassess the compliance program to identify changes necessary to reflect progress within the organization
The Office of Inspector General (OIG) has offered compliance program guidance for nursing facilities in multiple documents that identify six broad areas of risk for nursing facilities:
- Quality of Care
- Residents' Rights
- Billing and Cost Reporting Practices
- Employee Screening
- Kickbacks, Inducements and Self-referrals
- Recordkeeping and Documentation
Harmony (HHI) recommends a detailed analysis of the facilities most recent PEPPER to analyze the facility’s Medicare claims history. Ongoing monitoring of PEPPER target areas, along with routine, compliance focused chart reviews will assist the facility in ensuring documentation accurately reflects the level of care provided and services billed. Harmony (HHI) also recommends facility staff attend education to ensure the facility team has a strong knowledge base of the regulations related to reimbursement requirements for Medicare Part A and B, MDS completion and other Skilled Nursing Facility (SNF) regulatory requirements.
View Kris Mastrangelo's profile
