Compliance and Ethics Program Details
Jeannine LeCompte, Compliance Research Specialist
The CMS Compliance and Ethics Program—due for implementation November 28, 2019, is designed to ensure that all long-term care (LTC) facilities have a program in place to reduce exposure to criminal, civil, and administrative violations. Its content closely mirrors that of the existing OIG mandatory guidelines that became effective with the signing of the Affordable Care Act of 2010, and which are currently strictly enforced by OIG.
The State Operations Guidance to Surveyors for Long-Term Care Facilities specifies the minimum required components of such a compliance and ethics program as follows:
– Written policies and procedures which are “reasonably capable of reducing the prospect of criminal, civil, and administrative violations”;
– The 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;
– The setting out of disciplinary standards which detail the consequences for committing violations for the operating organization’s entire staff;
-The assignment of specific individuals “within the high-level personnel of the operating organization” to have overall responsibility to oversee compliance. Such officials could be the chief executive officer (CEO), members of the board of directors, or directors of major divisions in the operating organization;
– Steps to “effectively communicate” the standards, policies, and procedures in the operating organization’s compliance and ethics program to the operating organization’s entire staff. This must include mandatory training programs, orientation programs, or disseminating information that explains in a practical manner what is required under the program; and
– The utilization of a monitoring and auditing system reasonably designed to detect criminal, civil, and administrative violations.
Once a violation is detected, the facility must ensure that all “reasonable steps” are taken to respond appropriately to the violation and to prevent further similar violations, including, but not limited to, any necessary modification to the operating organization’s program.
Any organization which has five or more facilities must have a designated compliance officer for whom the operating organization’s compliance and ethics program is a major responsibility. This person must report directly to the operating organization’s governing body.
In addition, such facilities must have designated compliance liaisons located at each of the operating organization’s facilities.
Finally, all facilities must review their compliance and ethics program on an annual basis to ensure that any changes in applicable laws or regulations are accommodated.
