Kusserow on Compliance: Questions board-level compliance committees should be asking

HHS OIG compliance guidance calls for a Board-level committee to oversee the Compliance Program (CP). The HHS Inspector General noted that the best boards are those that are active, questioning, and exercise (constructive) skepticism in their oversight, asking probing questions about the compliance program. Boards need to know what type of questions they should be asking, and compliance officers should assist them with this problem. However, compliance officers in turn should be prepared to provide full and complete answers to them. The OIG and American Health Lawyers Association developed specific suggested questions that Board’s should be asking in their jointly produced “Corporate Responsibility and Corporate Compliance: A Resource for Health Care Boards of Directors” and “Corporate Responsibility and Health Care Quality (2007): A Resource for Health Care Boards of Directors”. The following are drawn from these advisory documents:

  1. Does the compliance officer have sufficient authority to implement the CP?
  2. What is the level of resources necessary to properly implement and operate the CP?
  3. Has the compliance officer been given the sufficient resources to carry out the mission?
  4. Have compliance-related responsibilities been delegated across all levels of management?
  5. What evidence is there that all employees are held equally accountable for compliance?
  6. How has the code been incorporated into corporate policies across the organization?
  7. What evidence is there that the code is understood and accepted across organization?
  8. Has management taken affirmative steps to publicize importance of code to employees?
  9. Have compliance-related policies been developed that address compliance risk areas?
  10. Are there policies/procedures for CP operation and how they should be reviewed/updated?
  11. What kind of document management ensures compliance-related documents are up to date?
  12. What is the scope of compliance-related education and training?
  13. What evidence is there of the effectiveness of CP training?
  14. What measures enforce training mandates and provide remedial training?
  15. What evidence is available that employees understand compliance expectations?
  16. How are compliance risks identified?
  17. What is the evidence that identified compliance risks are being addressed?
  18. Is the board being kept up to date on regulatory and industry compliance risks?
  19. How is the compliance program structured to address such risks?
  20. How are “at risk” operations assessed from a compliance perspective?
  21. Is conformance with the CP periodically evaluated?
  22. Does the CP undergo periodical independent evaluation of its effectiveness?
  23. What is the process for the evaluation and responding to suspected compliance violations?
  24. What kind of training is provided to those who conduct investigation of reported violations?
  25. How do the CO, HRM, and legal counsel coordinate in resolving compliance issues?
  26. What are the policies to ensure preservation of relevant CP documents and information?
  27. What policies address protection of “whistleblowers” and those accused of misconduct?
  28. What are the results of ongoing compliance monitoring by all program managers?
  29. How is ongoing compliance auditing being performed and by whom?
  30. How often is sanction-screening conducted and with what results?
  31. Are results from sanction-screening included in a signed report by the responsible parties?
  32. Has the CP been evaluated for effectiveness by a qualified independent reviewer?
  33. What evidence regarding effectiveness of hotline operation and follow-up investigations?
  34. What are the metrics being used to evidence CP effectiveness?
  35. What are the results of an independent review and assessment of the CP?

 

More information regarding available tools and resources available to assist in answering these questions, contact Daniel Peake at (dpeake@complianceresource.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.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Compliance document management

Controlling and managing compliance-related policies and procedures are among the most challenging areas for compliance officers and are a subject of great confusion. Kash Chopra, MBA and JD, works in assisting Compliance Officers with compliance related problems and has found that most organizations go about development of compliance policies in a haphazard and ad hoc manner that exposes them to a great deal of potential liability. She has frequently encountered organizations that do not properly keep track of policies with the result of overlapping or duplicate policies on the same subject that could create significant liability. The failure to keep track of rescinded or revised policies is another common problem with potential liability consequences. For Compliance Officers addressing this issue, she notes that policy management refers to all stages of document life cycle and is critical to an effective compliance program. This includes:

  1. Controlling all compliance-related documents
  2. Standardizing document form/format
  3. Establishing a need for a new document
  4. Prompting when action is needed
  5. Managing work flow in creation of new/revised documents
  6. Tracking when documents should be reviewed for updating
  7. Maintaining an archive of retired documents and policies
  8. Storing and managing all compliance-department documents
  9. Ensuring document access controls and security
  10. Establishing hyperlinks to related regulators and authorities
  11. Facilitating distribution to employees, vendors, and consultants
  12. Documenting certifications and attestations

For more information on this subject, contact KChopra@strategicm.com or (703) 535-1413

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: Meeting nursing home compliance program legal mandates

The November 28, 2019 deadline approaches for skilled nursing facilities and nursing homes to adopt and implement an effective compliance and ethics program as a condition of participation in the Medicare and Medicaid programs. At that time, state survey agencies will begin assessing facility compliance with implementation of an effective compliance and ethics program. Yet, the OIG continues to find major problems with that health care sector. The OIG recently reported that posthospital extended care services or Medicare beneficiary coverage must be preceded by an inpatient stay in a hospital for not less than three consecutive calendar days. The OIG found that CMS improperly paid 65 of the 99 skilled nursing facility (SNF) claims sampled by the OIG.  Projecting from its sample, the OIG estimated that CMS improperly paid $84 million for SNF services over a two-year period.

Those nursing homes that followed the OIG guidance will have little problem in meeting the new mandate, but those who did not have only months to come into compliance. Organizations trying to catch up should consider having a compliance expert perform a gap analysis to identify elements needed for the compliance program and how be able to evidence program effectiveness. A gap analysis should provide a “road map” and step-by-step plan for bringing a facility into compliance with the mandates. Those that have already implemented a compliance program should consider having an effectiveness evaluation conducted by experts to verify that the program will meet mandated standards.

For more information about meeting the standards of these new mandates, Tom Herrmann may be reached at thermmann@strategicm.com or at (703) 535-1410.

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 © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: CMS announced updates to nursing home ratings

CMS announced updates in April 2019 to Nursing Home Compare and the Five-Star Quality Rating System. Its purpose is to provide tools for consumers to compare quality between nursing homes. This comes in advance of the November 28, 2019 deadline for skilled nursing facilities and nursing homes to have implemented an effective compliance and ethics program as a condition of participation in the Medicare and Medicaid programs. The new tools announced have been created to help consumers, their families, and caregivers compare nursing homes and identify areas they may want to ask about when looking at nursing home care. Nursing Home Compare has a quality rating system that gives each nursing home a rating between 1 and 5 stars and those with 5 stars are considered to have above average quality and nursing homes with 1 star are considered to have quality below average. There is also a separate rating for each of the following three factors:

 

  1. Health Inspections include findings on compliance to Medicare/Medicaid health and safety requirements from onsite surveys conducted by state survey agencies at nursing homes.
  2. Staffing Levels are the numbers of RNs available to care for patients in a nursing home at any given time.
  3. Quality Measures for care are based on resident assessment and Medicare claims data.

 

The April 2019 changes include revisions to the inspection process, enhancement of new staffing information, implementation of new quality measures, and lifting of the “freeze” on the health inspection ratings instituted in February 2018 to hold up the star rating score until all nursing homes were surveyed at least once under the new survey process. In April, users of the site will be able to see the most up to date status of a facility’s compliance, which is a very strong reflection of a facility’s ability to improve and protect each resident’s health and safety. CMS is also setting higher thresholds and evidence-based standards for nursing homes’ staffing levels, recognizing that nurses have the greatest impact on the quality of care nursing homes deliver. As such, CMS is assigning an automatic one-star rating when a Nursing Home facility reports no RN is onsite. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days. The new Update includes:

 

  • changes to the quality component to improve the identification of quality differences among nursing homes, raising expectations for quality, and incentivizing continuous quality improvement;
  • adding measures of long-stay hospitalizations and emergency room transfers;
  • removing duplicative and less meaningful measures;
  • establishing separate quality ratings for short-stay and long-stay residents; and
  • revising the rating thresholds to better identify the differences in quality among nursing homes making it easier for consumers to find the information needed to make decisions.

 

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 © 2019 Strategic Management Services, LLC. Published with permission.