Jeannine LeCompte, Publishing and Research Coordinator
All long-term care facilities using Medicare or Medicaid funding are required to conduct annual assessments of their compliance and ethics programs to ensure that all aspects of their operations are in compliance with the law. This annual assessment must cover all situations relating to staff and contractors who provide services to the facility. In particular, the assessment must be able to prove that the facility has processes in place to identify and disclose conflicts of interest, and that all staff, contractors, and suppliers adhere in full to the company’s compliance policies.
Compliance obligations should be included in all staff job descriptions, and there should be inclusion of compliance accountabilities as an element of all staff performance evaluations. In addition, the assessment must be able to prove that all background checks are conducted in accordance with policies and procedures that reflect applicable rules and laws. It must also be demonstrated that there is a process in place to take corrective action based on background check findings.
The assessment must be able to show how the company monitors government sanction lists for excluded individuals or entities, and that due diligence is conducted on third parties such as consultants and vendors, and for mergers and acquisitions.
The assessment must also be able to show how the company implements counseling and discipline for noncompliance incidents among staff, vendors, or suppliers. This should include recommended disciplinary action in the cases of proven noncompliance, and show that the discipline is in proportion to the seriousness of the violation.
Compliance-related violations should be addressed in the disciplinary policies. Discipline should be shown to be enforced consistently throughout all levels of the organization and this consistency of application should be fully documented and provable.
Finally, the assessment must be able to show that in all cases, timely disciplinary action is taken after noncompliance issues are first noted, and that all disciplinary actions and outcomes are reported to the relevant regulatory body as required by law. This assessment must be kept on record for inspection by the authorities.
