Kusserow on Compliance: The relationship between an Interim Compliance Officer and the CEO

Getting the right start is the best way to have a good return on investment

Catie Heindel, J.D., a highly experienced compliance consultant who has served as an Interim Compliance Officer, notes it is increasingly common for healthb care organizations to seek a temporary compliance officer to cover a gap. Though the rationale behind hiring an interim compliance officer is different for every organization, the ultimate goal is usually the same—to provide high quality and efficient compliance program leadership that will reduce exposure to unwanted risks and problems. Preparation and communication with staff to introduce the person selected to act in an interim capacity is very important to having a successful result from the engagement.

Ensuring a successful hiring decision really needs the personal involvement of the CEO. The OIG compliance guidance stresses that the compliance officer should report directly to the CEO. This sentiment also applies to Interim Compliance Officers; and the best return on investment for having someone move in and successfully temporarily fill a compliance officer gap is for the CEO to establish a direct reporting relationship. It is also helpful for everyone involved if the CEO personally provides a detailed background briefing on the organization that includes:

  • management structure;
  • mission/vision;
  • why the person was engaged;
  • expectations for the engagement; and
  • their role in the organization.

Upon arrival, the CEO should ensure there is a proper “on-boarding” process that includes personally introducing the interim compliance professional to the executive leadership, key program managers, legal counsel, HRM, and Board members. This interaction, from the outset, sets the right tone and will help to ensure that the interim is in lockstep with the CEO.  Furthermore, this empowerment exercise will permit the interim to move more quickly in gathering the reins of the compliance program and guard against having anything fall “beneath the cracks”.  It will also help the interim compliance professional to “hit the ground” running immediately and begin productive work.

For more information regarding engaging and preparing Interim Compliance Officers, Catie Heindel can be contacted at www.cheindel@strategicm.com, or via phone at (847) 707-9830.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Time running out for nursing and long term care providers’ development of mandated compliance programs

Tips to meet the challenge in a timely and cost effectively manner

The OIG issued voluntary Compliance Program Guidance for Nursing Facilities in March 2000, followed by Supplemental Compliance Program guidance in September 2008. However, the Patient Protection and Affordable Care Act (ACA) made compliance a mandate and it is a game changer for this sector. The new mandates note as a condition of enrollment in Medicare and Medicaid “a facility shall . . . have in operation a compliance and ethics program. . . .”   HHS was directed to issue regulations “for an effective compliance and ethics program for operating organizations” and CMS has issued those regulations with a deadline for organizations and facilities to meet these requirements by November 28, 2019. At that time, state survey agencies will begin assessing facility compliance for compliance.

Tom Herrmann, J.D., served over 20 years in the OIG Office of Counsel and for the past ten years has been a compliance consultant, specializing in nursing home compliance programs. He noted that many nursing facilities lagged behind in developing effective compliance programs because it was viewed as cost prohibitive. Those that implemented programs following the OIG guidance will have little difficulty in meeting the standards. For those who delayed program development, time is running out. State survey agencies will conduct compliance audits following the CMS State Operation Manual “Guidance to Surveyors for Long Term Care Facilities”.  Survey protocols and guides for State Survey Agencies have also been posted by CMS and can be reviewed by nursing homes in preparation for the reviews.  When building or improving the compliance program, CMS requires an annual review of its compliance and ethics program to assess the resources needed for an effective compliance program that includes mandatory training for all covered persons. For more information regarding advisory services in building effective compliance programs, Tom Herrmann can be reached at therrmann@strategicm.com or via phone at (703) 535-1410.

Kash Chopra, JD, provides compliance staffing for clients. She explained that many nursing homes may not require hiring a fulltime compliance office, however, designating someone on the staff to act as a compliance officer as a secondary duty is not a good idea and seldom works satisfactorily. Invariably, the primary duties drive out time for the compliance responsibilities.  One solution that should be considered is using an expert as a Designated Compliance Officer (DCO) to quickly, efficiently, and inexpensively build and manage the program. The OIG in its compliance program documents specifically advises: “For those companies that have limited resources, the compliance function could be outsourced to an expert in compliance.”  For more on staffing compliance officers, Kash Chopra can be reached at 703-236-1291 or at kchopra@strategicm.com

Daniel Peake of the Compliance Resource Center said that many nursing home clients have found an economical solution to the costs of building and managing their compliance program by outsourcing key elements, such as hotline services, sanction screening, compliance training, code and policy development. These services can take a big bite out of the work of building an effective compliance program at a very small price for most organizations providing nursing or long term care. For more information about the cost and benefits of outsourcing key compliance elements, Daniel Peake can be reached at (dpeake@compliancereource.com (703)-236-9854).

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Physicians must comply with sharing patient information

Under the electronic health records (EHR) metric, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10) requires attestations from doctors that they are not knowingly and willfully limiting or restricting their EHR’s ability to share information with providers that may have different record systems.  CMS has issued new guidance reminding providers of their responsibilities to promptly share medical information with patients and other clinicians, or else face financial penalties. The targets are providers participating in the Merit-based Incentive Payment System (MIPS) to comply with MACRA. The notice stated physicians will need to attest that they are not engaged in information blocking and that they give patients their data in a timely fashion. Many physicians and medical practices use vendors for their information management systems. They will now have to ensure their vendors enable them to comply with the information sharing mandates.

Under MIPS, providers become eligible for either bonus payments or penalties based on their performance, including evidence of quality improvement, cost reduction or maintaining current levels of spending; efficient use of EHRs; and clinical improvement activities such as later office hours and greater use of care coordination. The Prevention of Information Blocking Attestation has three related statements for MIPS eligible clinicians:

  1. They did not knowingly and willfully take action to limit or restrict the compatibility or interoperability of Certified EHR Technology (CEHRT).
  2. They implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure the CEHRT was connected and compliance with applicable law and standards for timely access by patients to their data and other health care providers.
  3. They responded in good faith and in a timely manner to request to retrieve or exchange EHR from patients and other health care providers.

CMS also stated that physicians would not be held accountable for things outside of their control, but must get adequate assurances from their vendors that they are able to comply with the information sharing requirements. On the other hand, physicians must take care that they don’t violate the HIPAA Privacy law for patient Protected Health Information (PHI).

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG report on research compliance through OHRP

The OIG conducted a study of the Office of Human Research Protection (OHRP) at HHS in response to Congressional requests that raised questions about its independence. The request was for the OIG to review OHRP procedures and make recommendations to strengthen protections for human subjects and ensure OHRP’s independence. OHRP enforces compliance with HHS regulations for protecting human subjects. Its mission is to protect the rights of human subjects-individuals who volunteer to participate in research conducted or supported by the HHS. The OIG conducted a survey of research institutions that were the primary subjects of the compliance evaluations about their experiences with the OHRP. The OIG also reviewed documents from eight compliance evaluations that had been closed; and interviewed OHRP staff, other HHS officials, and individuals with expertise in protections for human subjects.

OIG findings regarding OHRP

The OIG found that OHRP:

  • evidenced carrying out its compliance activities independently from agencies funding the research and the institutions conducting the research;
  • made decisions on how to use resources, resulting in fewer compliance evaluations, while increasing its use of other mechanisms in response to allegations;
  • determined the scope of its evaluations and what methods to employ;
  • was able to access the information it needed to conduct its compliance evaluations;
  • maintained documentation on its determinations;
  • may be limited in its ability to act independently due to its role, placement within HHS, and the way its budget is set may limit; and
  • may have the appearance of limited oversight and independence due to the practice of not reporting publicly on all of its compliance activities.

OIG Recommendations to HHS

The OIG recommended that HHS:

  1. issue guidance that clarifies OHRP’s role;
  2. re-evaluate OHRP’s position within HHS;
  3. evaluate sufficiency of OHRP’s resources;
  4. consider ways to elevate the prominence of OHRP’s budget (e.g. having a separate line item in the President’s budget);
  5. foster a shared understanding for OHRP’s independence by considering seeking statutory authority for OHRP’s independence; and
  6. post on OHRP’s website: (a) a description of its approach to oversight and (b) data (in aggregate) regarding its compliance activities.

 

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.