Jeannine LeCompte, Publishing and Research Coordinator
Medicare- and Medicaid-approved Skilled Nursing Facilities (SNFs) are under a legal obligation to have a compliance program which adheres to the guidelines laid down by the Office of the Inspector General (OIG). The full extent of the work involved makes it impracticable for it to be undertaken by other staff as an additional duty. For this reason a compliance officer should be appointed to be responsible for the implementation of a compliance program. This individual should work to ensure that all of the required tasks are fulfilled. A failure to implement any part of the compliance program can have serious implications for the SNF in the event of an OIG investigation.
The compliance officer should make sure that:
- All employee background checks are conducted in accordance with rules and regulations;
- All individual(s) responsible for employee and vendor exclusion screening have clear accountability for that function. In other words, there must never be any doubt as to who takes responsibility for all employee, vendor, and third-party background screenings;
- All job descriptions, training material, orientation material, and annual performance evaluations of the individual(s) responsible for exclusion screening are clearly articulated and performance is measured;
- An annual review of the exclusion screening process is taken to ensure that it meets all the documentation retention requirements;
- A complete audit process is in place to ensure that all employees and vendors are screened before and during employment;
- A detailed process exists to deal with the eventuality of a screening process returning an unexpected negative result;
- All employees and vendors are fully aware of the compliance program, and the facility obtains written confirmation thereof;
- Procedures are in place to prevent the hiring of an ineligible individual or entity;
- All job descriptions, training/orientation materials, and annual performance evaluations are audited;
- All the conflict of interest disclosures and attestations are completed and signed; and
- Staff and vendors alike are interviewed to ensure that all compliance training is understood and being implemented.
