Nursing Home Compliance Program – The Who, What, When, Why and How

Nurse standing outside a nursing home being reminded of the facility compliance plan.

Nursing Home Compliance Program – the term elicits a myriad of reactions from providers, ranging from indifference to anxiety.  Regardless of your feelings, the requirement for a SNF compliance program is here to stay and you’d best be running a good one right now.  Recently, I had the opportunity to sit down with Jim Hook, our Director of Consulting Services at The Fox Group, LLC, to pick his brain on the subject of nursing home compliance programs.

Why spend time and money on a nursing home compliance program?

There are several reasons for developing and implementing an effective nursing home compliance program, but one of the most important ones is the fact that it is required under the Affordable Care Act (“ACA”).  Section 6102 of the ACA includes a mandate for nursing facilities to have effective compliance and ethics programs in operation by March 23, 2013.  It should be noted that the requirement is to have an effective nursing home compliance program, not one where a written manual sits on the shelf, employees are never trained, and auditing and monitoring never takes place.

Isn’t the OIG more focused on other providers, not long term care?

CMS and the OIG are focused on many types of providers, including long-term care facilities.  A quick perusal of the list of corporate integrity agreements which have been imposed upon healthcare providers shows that many skilled nursing facilities and skilled nursing facility companies have run afoul of Medicare or Medicaid rules, and now have corporate integrity agreements in place.

And yes, we know all about that, since we are often engaged to be the required IRO.  Corporate integrity agreements typically require you to hire an independent review organization (“IRO”) to review claims or arrangements with physicians that were the source of problems identified by the government.  This represents an added cost to the facility.

The major difference between a corporate integrity agreement imposed by the government and a nursing home compliance program which you voluntarily develop is that you must report all of your compliance activities to the OIG during the corporate integrity agreement period.  It is far preferable to manage your own program than to be forced to report your compliance activities to the OIG for a five-year period.

What are the benefits of a nursing home compliance program?

Let me list a few key ones:

  • an effective compliance program can demonstrate the facility’s commitment to honest and responsible corporate conduct;
  • an effective program increases the likelihood that you will identify, prevent and correct unlawful or unethical behavior at an early stage;
  • an effective compliance program can be used to encourage employees to report potential problems for appropriate internal investigation and corrective action to minimize potential financial losses;
  • an effective compliance program can enhance the organization’s operations, improve quality of care, and even reduce overall costs;
  • an effective compliance program is also an element considered by the government when imposing fines or other penalties.  Such fines or penalties can be reduced by up to 90% when a facility can demonstrate it has had an effective compliance program.

A nursing home compliance program just makes good business sense.

Nursing home operators live in a litigious and highly regulated environment – it was that way when I started in the business 35 years ago and it remains true to this day.  And, there’s no sign of it changing in any way.  So doesn’t it make sense to live by the old adage, “an ounce of prevention is worth a pound of cure” especially when that “cure” includes the multitude of punitive actions available to the government?

James Hook, MPH The Fox Group, LLC

In this case, one of the tools available to you as a part of that “ounce of prevention” is an effective, dynamic and active nursing home compliance program.  Look, it’s not castor oil (for those of us old enough to remember that!) so go ahead and get started on your program today!  If you already have one – a big congrats (take a moment to pat yourself on the back) but check back on our next blog installment which will give you tips on key elements of a nursing home compliance program.

Thanks Jim for lending your expertise to our discussion about nursing home compliance programs.  In our next blog installment, we’ll tackle some additional questions/issues, including setting up a skilled nursing compliance program.  Stay tuned!

When you need proven expertise and performance

Craig Fukushima, NHA, MBA

Mr. Craig T. Fukushima’s health care experience spans more than 35 years with special expertise in the long term care sector, including implementation of innovative health care projects in domestic and international locations.