Compliance and Ethics Program (Phase 3) – 42 CFR § 483.85

Recorded On: 03/15/2019

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** In July 2019, CMS proposed several changes that would affect the compliance and ethics section in the Requirements of Participation, including delaying implementation of this requirement for a year from the date the rule is finalized. AHCA recommends providers continue implementing the requirement because it is unknown if or when CMS will finalize the proposal. As of now, the regulations still require providers be in compliance as of November 28, 2019. AHCA will continue to closely monitor and notify members when any changes are finalized. **

As part of the Requirements of Participation (RoP) Phase 3, nursing centers must have a Compliance and Ethics Program that meets specified requirements. Starting November 28, 2019, CMS and state survey agencies will be authorized to issue survey deficiencies under federal Ftag F895 to centers that do not have an effective compliance program.

AHCA has created a webinar series and resources to support members in developing or adapting their existing program to meet this requirement. Although the interpretive guidelines have not yet been published (as of September 2019), the RoP Compliance and Ethics Program stems from the Office of Inspector General’s (OIG) long-standing guidance for the 7 elements of a compliance program. The numbering and titling of the specific elements within an effective Compliance and Ethics Program can be different, yet the content generally remains the same, with a few specific additions in the RoP. So even though CMS has not yet released guidance for the Compliance and Ethics Program, reviewing existing OIG resources will support a nursing center to develop an effective compliance program overall. This webinar series and the AHCA toolkit offers tools and distills the information into a webinar series to provide practical explanation and tips for how to create or update your compliance program.

 This webinar series are presented by various compliance experts. It includes:

  • Overview
  • A different session on each of the 7 elements for an effective compliance program and how this fits in with the RoP Compliance and Ethics Program
  • The Interdependence between Compliance, Ethics and Quality
  • What Administrators and Compliance Liaisons Need to Know

Key:

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AHCA Toolkit ROP Compliance and Ethics Program
Open to download resource.
Open to download resource. Starting November 28, 2019, nursing centers must have a Compliance and Ethics Program that meet the standards outlined in the Requirements of Participation. Creating an effective program requires advanced planning to have in place the appropriate staff, training, and policies and procedures. This toolkit is a concise summary of the requirements with helpful, practical tips for implementation. It also pulls in best practices from a variety of sources to support providers in building or improving their program. While we wait for interpretative guidelines to provide additional clarity, the information in this toolkit will help providers plan for phase 3 implementation.
Compliance and Ethics Training Sample Checklist
Open to download resource.
Open to download resource.
Monitoring and Auditing Risk Assessment Sample Tool
Open to download resource.
Open to download resource.
AHCA FAQ § 483.85 Compliance and Ethics Program
Open to download resource.
Open to download resource.
Compliance & Ethics Program § 483.85- Action Brief
Open to download resource.
Open to download resource. Purpose & intent of § 483.85: Develop, implement and maintain a Compliance & Ethics program that requires, at a minimum, 8 elements.
Compliance & Ethics: Overview of the Requirements of Participation for Nursing Facilities
RoP Compliance and Ethics Program: Overview
Recorded 02/21/2019
Recorded 02/21/2019 o This webinar provides an overview of the Compliance and Ethics Program from the RoP Phase 3. The speakers review the components required for the Compliance and Ethics Program. In addition, they will cross-walk these requirements with the 7 elements of an effective compliance program: (1) policies, procedures, and standards of conduct; (2) compliance program oversight and administration; (3) screening and evaluation of employees, physicians, vendors and other agents; (4) communication and education; (5) monitoring and auditing; (6) enforce standards; and (7) investigate and undertake corrective action. Presenters: Sarah Couture, Senior Director at Ankura Consulting Group, LLC John Daily, CEO at Management Advisors, Inc
RoP Compliance and Ethics Program: What Administrators and Compliance Liaisons Need To Know
Recorded 04/04/2019
Recorded 04/04/2019 o Administrators have a critical role in the ongoing success of their building's Compliance and Ethics Program in the Requirements of Participation. For smaller organizations (less than 5 buildings), the administrator may be the assigned individual with overall responsibility to oversee compliance. Organizations with five or more buildings will have single Compliance Officer, but must also have designated "compliance liaisons" located in each building. Although the compliance liaisons are not responsible for the overall program and education, they have a critical role ensuring a culture of compliance and an effective program in their building. This session is geared towards administrators and designated compliance liaisons to understand their role and the essential elements of a Compliance and Ethics Program. Presenter: Pam Duchene, Vice President Education & Training at Harmony Healthcare International
The Interdependence between Compliance, Ethics and Quality
Select the "View On-Demand Recording" button to begin.
Select the "View On-Demand Recording" button to begin. o What does it mean to promote quality in the context of a Compliance and Ethics Program? This session will explore the possible collaborations and overlap between QAPI and the compliance program. Presenter: Presenter: Demi Haffenreffer, CEO at Haffenreffer and Associates.
RoP Compliance and Ethics Program: #1 Written Policies, Procedures, and Standards of Conduct
Recorded 03/19/2019
Recorded 03/19/2019 o To establish a successful Compliance and Ethics Program, nursing centers need to have written compliance and ethics standards, policies, and procedures that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under the Act and promote quality of care. This session will review what policies and procedures are needed and the components of a successful policy and standards of conduct. Presenter: Todd Selby, Attorney at Hall, Render, Killian & Lyman
RoP Compliance and Ethics Program: #2 Compliance Program Oversight and Administration
Recorded 03/20/2019
Recorded 03/20/2019 o To create and maintain an effective compliance program, nursing centers must assign high-level personnel of the operating organization with the overall responsibility to oversee compliance with the operating organization’s compliance and ethics program’s standards, policies, and procedures. This session will review compliance program oversight and administration to comply with the requirements of participation, including screening potential employees. Presenters: Sarah Couture, Senior Director at Ankura Consulting Group, LLC John Daily, CEO at Management Advisors, Inc
RoP Compliance and Ethics Program: #3 Screening and Evaluation of Employees, Physicians, Vendors and other Agents
Recorded 04/04/2019
Recorded 04/04/2019 o Screening and evaluation of employees is critical to having a compliance program that is reasonable designed and implemented to be effective in preventing and detecting violations and in promoting quality of care. This session will provide practical tips to help nursing centers screen staff, identify and address potential conflicts of interest, and include compliance accountabilities as an element of performance evaluation. Presenter: Pam Duchene, Vice President Education & Training at Harmony Healthcare International
RoP Compliance and Ethics Program: #4 Communication
Select the "View On-Demand Recording" button to begin.
Select the "View On-Demand Recording" button to begin. o Having open lines of communication and education is critical to the success of a compliance program so that employees feel comfortable and know how to report concerns. Learn about communication best practices for a compliance program and for meeting the RoP provision to effectively communicate standards, policies, and procedures. Presenter: Demi Haffenreffer, CEO at Haffenreffer and Associates.
RoP Compliance and Ethics Program: #5 Auditing and Monitoring
Recorded 03/28/2019
Recorded 03/28/2019 o Session description: Auditing and monitoring are the foundation of a compliance program. Learn about the steps to audit and monitor, including a drill down into performance auditing. The speaker will walk through a sample risk assessment tool provided for members and auditing sampling methods. Presenter: Bill Ulrich, CEO/President at Consolidated Billing Services Inc
RoP Compliance and Ethics Program: #6 Enforcement and Discipline
Recorded 03/20/2019
Recorded 03/20/2019 o The Requirements of Participation Compliance and Ethics Program necessitates consistent enforcement of the organization’s standards, policies, and procedures through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect and report a violation to the compliance and ethics program contact. This session covers enforcement and discipline with practical tips how to create a culture of compliance, such as a focus on tone at the top, code of conduct, values-based culture, and the effective use of positive and negative incentives. Presenters: Sarah Couture, Senior Director at Ankura Consulting Group, LLC Kaitlin Lavin Senior Associate at Ankura Consulting Group LLC
RoP Compliance and Ethics Program: #7 Investigate, Respond and Undertake Corrective Action
Recorded 04/04/2019
Recorded 04/04/2019 o A Compliance and Ethics Program requires a consistent process for investigations and undertaking remedial measures. The process requires communication of noncompliance, investigating, and as needed developing and monitoring a corrective action plan. This session will review the basics for investigating and responding to potential noncompliance. Presenter: Todd Selby, Attorney at Hall, Render, Killian & Lyman
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