Harmony Healthcare Blog

Compliance Series: 7 Elements of An Effective Compliance Program 2019

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Thu, Jan 24, 2019

Find me on:

Edited by Kris Mastrangelo


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

close up of a calendar-294139-editedCMS revised paragraph §483.85(b) to accurately indicate that the operating organization for each Skilled Nursing Facility must have in operation a Compliance and Ethics program by November 28, 2019, (Phase 3). A technical error occurred on page 68869 of the October 4, 2016, Final Rule.  CMS incorrectly stated that the each facility must have an in operation compliance and ethics program by November 28, 2017.  CMS corrected this error. 

The implementation of an effective Compliance Program takes years to perfect.  While the deadline is 10 months away, every Nursing Facility must begin today! The concept of compliance is not new and is an integral component of many industries, including banking, defense and international business. The arrival of compliance within the SNF sector was certainly catalyzed by the massive influx of whistleblowers in 2012 and 2013.  Compliance and Ethics is a culture.  It is a top down messaging of the organization’s goals and philosophies.  The ultimate objective of the program is to bake systems and safeguards within your structure to: 

  • Identify Issues
  • Prevent Issues
  • Correct Issues 

Patient-Driven Payment Model (PDPM)

With the overarching intent of the organization to comply, in good faith and to the best of its ability and knowledge, with all State and Federal Laws. To assure a commitment to compliance, it is necessary to develop and implement a Compliance Program with the following key elements: 


  1. Policies and Procedures
  2. Reporting and Investigating
  3. Education and Training
  4. Prevention and Response
  5. Auditing and Monitoring
  6. Responsibility/Oversight of Compliance Officer/Committee
  7. Enforcement, Discipline and Incentives 

Over the next 7 blog posts, I will review each element to help you jump-start your Compliance and Ethics Program.

Harmony Healthcare International (HHI) is available to provide assistance You can contact us by clicking here. Looking to train your staff?  Join us in person at one of our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

harmony20 October 29-30 2020 Encore Boston Harbor

Tags: Compliance

Subscribe to The HHI Blog

Posts by Topic

see all
New Call-to-action

Stay connected!