Jeannine LeCompte, Publishing and Research Coordinator
Annual long-term care facility (LTC) compliance reports must show that the facility has taken all measures possible to ensure a suitable level of care is provided to residents—keeping in mind that a failure to do so constitutes a serious breach of Medicare and Medicaid rules.
LTCs are required to meet minimum duty of care rules, and to highlight in all reports exactly how this duty of care has been guaranteed and maintained. At a minimum, the annual assessment has to demonstrate that the LTC has the following:
- Written compliance and ethics standards, policies, and procedures capable of reducing the prospect of criminal, civil, and administrative violations and promoting quality of care
- Designation of an appropriate compliance and ethics program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution
- An assurance that all policies and procedures address the compliance role in quality of care issues
- Written policies which clearly define the different categories of abuse and neglect, and are spelled out to all personnel so that there can never be any doubt about what constitutes lack of care
- Disciplinary standards that set out the consequences for committing violations for all staff, contractors, and subcontractors
- The use of monitoring and auditing systems reasonably designed to detect criminal, civil, and administrative violations
- A process whereby all reasonable steps are taken to respond appropriately to prevent the reoccurrence of any violation, including any necessary modification to the LTC’s oversight structure
- A due diligence process which must include regular and ongoing checks to ensure that all personnel, contractors, and subcontractors are not on the federal exclusion lists
- A written code of conduct exists, and all personnel, contractors, and subcontractors are aware of this code and their legal obligations to adhere to it.
- Codes of conduct are part of ongoing training and education
A failure to adhere to the standards of care as required by the Department of Health and Human Services (HHS) and other bodies can lead to severe consequences for the individuals involved and also for the LTC.
