Auditing and Monitoring Ethics Committees
Jeannine LeCompte, Compliance Research Specialist
Even though the roles of an ethics committee and a compliance and ethics committee are distinct, the end results of their decisions should be monitored and audited in the same way. The first requirement of this process is the establishment of a comprehensive internal audit system which can review all decisions, gather data, and benchmark progress (or the lack of) to the stated goals. The auditors should provide written reports to the compliance officer and other senior management which outline findings, recommendations, and proposed corrective actions.
Reviews should be undertaken on a periodic basis to ensure that circumstances have not changed dramatically. While there is no legal definition of what constitutes “periodic,” it is a matter of common sense that such a review should be undertaken annually at the very least.
Compliance committees are tasked with implementing legal and ethical guidelines, while auditors are tasked with uncovering deliberate fraud and cover-ups. Auditors therefore have to be independent from the facility’s management team, and have access to the relevant personnel and all operational areas.
Focus areas for auditors should include, but not be limited to:
- falsification of documents
- inflation in the number of claims processed
- misuse of trust funds, altered documents
- improperly adjusted cost reports
- ongoing processing errors
While some areas of the ethics committee might not have legal sanction—for example, questions relating to a moral decision not bound by any specific law—the facility should not de-prioritize decisions by the ethics committee. There is a moral compunction on the facility to uphold the ethical rights of residents, and evidence that the residents’ rights have been prioritized may prove helpful in the unfortunate event of civil action.
The facility should ensure that internal investigation case files are consistently documented to show, at a minimum, the substance and date of the complaint, investigative actions taken, a narrative description of the resolution of the matter, and the date of closure.
When potential fraud or False Claims Act liability is not involved, the facility should use normal administration channels to report and resolve noncompliance with Medicare program requirements. However, where the compliance officer has credible evidence of misconduct from any source and has reason to believe it may violate criminal, civil, or administrative law relating to the Medicare program, then the misconduct should be reported to the Office of Inspector General (OIG) and CMS within 30 days of discovery.
