The Workings of a Compliance and Ethics Committee in the LTC Environment
Jeannine LeCompte, Compliance Research Specialist
The primary purpose of a compliance and ethics committee, according to the Centers for Medicare & Medicaid Services (CMS), is to “establish a culture within an organization that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal and state law, or to federal healthcare program requirements.” This highlights the difference between a compliance and ethics committee and an ethics committee—the former is primarily aimed at adhering to legal requirements, while the latter is more focused on moral and ethical issues.
A compliance and ethics committee should make use of its facility’s written standard of conduct and compliance policies and procedures. These documents, ideally developed under the direction of a dedicated compliance officer (CO), should clearly state a commitment to comply with all applicable statutory and regulatory requirements.
Tasks for the committee should include defining the duties and responsibilities of the CO, the training of employees with regard to maintaining standards, procedures for identifying and reporting noncompliance issues, interaction with auditors and the Human Resources (HR) department, establishing and maintaining background screening for staff, and conducting reviews of the code of conduct and the compliance policies and procedures.
In addition, the committee must ensure that the facility maintains a retention schedule for Medicare documents and records in accordance with CMS requirements, and ensure that adherence to the code of conduct, timely reporting and proper handling of compliance violations, and attendance at compliance training are all elements of employee and manager performance evaluations.
The committee must also ensure that general compliance training is provided to all employees, officers, managers, supervisors, board members, and long-term temporary employees. This training should communicate the essential requirements of the compliance program, including the company’s code of conduct and applicable Medicare statutory, regulatory, and contractual requirements. The committee should also be tasked with ensuring that there are suitable mechanisms in place for employees and others to report suspected or actual acts of noncompliance without fear of victimization or retaliation.
In summary, the compliance and ethics committee’s purpose is to ensure that the facility adheres to all legal requirements. This protects the rights of residents and avoids legal sanctions from the authorities.
