Skilled nursing facilities (SNFs) receiving federal funds are obligated to adhere to all legal and ethical standards. Making sure that the correct infrastructure and policies are in place is the first step in meeting this demand for compliance. It is vital that someone takes responsibility for all compliance matters—preferably a designated compliance officer, backed by a compliance committee.
The compliance officer—who, in some states, cannot be the facility’s administrator—must ensure that the SNF’s day-to-day operations meet all the legal demands. In order to do this, the officer will ensure that all mechanisms for reporting, monitoring, educating, interviewing, auditing, investigating, tracking, updating, and summarizing are in place and working.
A compliance committee should meet quarterly, or as often as the situation demands, to review all the reports on compliance activities. Committee members should ensure that they are fully up to date on all the issues and standards specific to nursing homes, and that the compliance program always reflects the latest state, national, and industry standards. They should also be able to make recommendations on revising existing policies. In addition, the committee must put into place procedures to ensure an appropriate response to compliance issues and oversee all disciplinary actions.
The compliance officer must issue a report on an annual basis to the senior administration, the governing body, and the board of directors/owner(s) that describes compliance efforts that have taken place during the year and that identifies any changes to the compliance plan that need to be made to improve its effectiveness. The report should include the audit plan, all audit results, all reports of noncompliance, all investigations into alleged noncompliance and their results, and all responses and corrective actions.
In order to ensure that all the above happens, it is also necessary to have written policies and procedures in place. These should describe compliance expectations, identify how to communicate compliance issues with appropriate personnel, and describe how potential compliance problems are to be investigated and resolved. The policies and procedures will ensure that all employees understand and meet the legal and ethical standards that govern the business, and will help detect—or preferably prevent—all activities that do not conform to the legal requirements.
