Jeannine LeCompte, Publishing and Research Coordinator
Medicare- and Medicaid-approved long-term care facilities are under a legal obligation to ensure that their governing bodies are fully informed of all relevant compliance issues, policies, and operational management tasks undertaken by their personnel.
The Code of Federal Regulations Title 42 (Chapter IV, § 483.70) requires a governing body to act in good faith in the exercise of its oversight responsibility for its organization, including making inquiries to ensure:
1) a corporate information and reporting system exists, and
2) the reporting system is adequate to ensure the governing body that appropriate information relating to compliance with applicable laws will come to its attention in a timely manner, and as a matter of course.
This means that a communication policy must be established which ensures that:
- Services are provided in accordance with facility policies
- Policies are current and reflect an acceptable standard of care
- Care is coordinated among the staff
- There is efficient use of resources
This communication policy can consist of formal meetings and presentations, or informal communications such as one-on-one meetings, phone calls, and emails. The process must be fully documented and available for review by the relevant authorities should the need arise.
According to the Centers for Medicare & Medicaid Services (CMS), the existence of a corporate reporting system is a key compliance program element. It keeps the governing body informed of the activities of the organization, and enables a speedy evaluation of, and response to, potentially illegal or otherwise inappropriate activity.
As such, governing bodies are encouraged to use widely recognized public compliance resources as benchmarks for their organizations. These include the Office of Inspector General’s (OIG) voluntary compliance program guidance documents and Corporate Integrity Agreements (CIA), both of which can be used as baseline assessment tools for governing bodies to determine which specific functions may be necessary to meet the requirements of an effective compliance program.
The OIG’s voluntary compliance program guidance “offer[s] incentives to organizations to reduce and ultimately eliminate criminal conduct by providing a structural foundation from which an organization may self-police its own conduct through an effective compliance and ethics program.” The CIA guidance is helpful in assisting governing bodies seeking to evaluate their organizations’ compliance programs.
In addition, a governing body must be able to demonstrate to the OIG that it has made efforts to increase its knowledge of relevant and emerging regulatory risks, the role and functioning of the organization’s compliance program in the face of those risks, and the two-way flow and elevation of reporting of potential issues and problems to senior management.
