Note: the following sample auditing and monitoring process is based upon a similar sample we have used throughout this compliance guidance. It is designed to be a sample only, to assist providers in developing their own auditing and monitoring program, and to demonstrate one possible way of thinking about and approaching auditing and monitoring the issue of sufficient staffing. We’ve approached auditing and monitoring in this sample as a series of three categories of questions designed to prompt providers to ask key questions that can help avoid and detect potential kickback violations, consisting of the following questions:
- Specifically what are we auditing and monitoring (i.e., what are the specific issues we are looking for in this part of our auditing/monitoring process)?
- What specific sources of information will we examine to find that information (e.g., facility contracts, invoices for services or items purchased, interviews with facility staff and outside contractors, referral patterns and sources, etc.) and specifically, who in the facility or company (by title) will be responsible for each of the individual information source examinations and on what schedule (i.e., how often and when) will they perform these tasks?
- What will we do with the information we obtain as a result of steps 1 – 3, above?
Specifically what are we auditing and monitoring (i.e., what are the specific issues we are looking for in this part of our auditing/monitoring process)?
- Do we have a system in place to ensure sufficient staffing to meet the needs of our residents? How do we know if the scheduled staff is sufficient to meet the needs of the residents? How is this process documented?
- Do we have pre established staffing ratios and skills mix requirements?
- Are there policies and procedures in place that address sufficient staffing?
- Do we have a mechanism available to identify the resident’s needs, such as an acuity tool? If not, what do we use to identify resident’s needs? How is the review of resident’s needs documented?
- How do we schedule staff? Do we take into consideration, skill mix and competencies?
- How frequently do we monitor appropriateness of staffing levels?
- What is the process for budgeting staffing levels? Does the DON participate in the budgeting process? What data is reviewed to determine appropriate staffing budget?
- What is the process for determining if more (or less) staff is required? Is this done real time, during the budget process or both?
- Do we monitor for both over and understaffing?
- How are decisions made regarding replacement of call ins? Are call-in replaced with same skill mix and competency? How is this documented?
- What happens when staffing levels do not meet the criteria for sufficient staffing? How do we document our decisions and communicate to staff?
- Is staff aware of the system we use to ensure sufficient staffing? In general is there agreement with the staffing methodology? If not, is there an opportunity for dialogue?
- What is the process we use to communicate appropriateness of staffing levels to corporate (If NH is part of a corporation)?
What specific sources of information will we examine to find that information and specifically, who in the facility or company (by title) will be responsible for each of the individual information source examinations and on what schedule (i.e., how often and when) will they perform these tasks?
- The Administrator is ultimately responsible for sufficient staffing levels in the facility, and should work with the DON is audit and monitor levels.
- The audit process can be conducted by the Administrator, DON or delegated to (define)
- The audit process should be conducted regularly. The frequency should be defined in the facilities policies and procedures
- The following information sources will be reviewed during the audit
- Staffing data
- Assignment sheets
- Payroll data
- Schedule
- Resident Data
- Census including number of admissions
- Resident acuity measure, if available
- Case Mix
- Care Plans for information regarding residents with special needs (behavioral issues)
- MARs and TARs
- Adverse events reports related to resident issues, such as falls
- Staff Skills and Competencies
- Personnel records
- Training records
- Competency validation records
- Feedback
- Information regarding family concerns and complaints
- Customer satisfaction survey results
- Interview with residents, families and staff
What will we do with the information we obtain as a result of steps 1 – 3, above?
- The results of the above inquiries will be reviewed on a regular basis by the facility leadership team.
- A plan will be developed and implemented for any identified problems
- Policies and procedures will be changed, as necessary.
- As appropriate, the Compliance Officer or facility Administrator will discuss the results of these audits with senior management and/or the Board of Directors (or owners) and determine whether any additional measures are required or recommended, whether additional compliance safeguards should be instituted at the facility (including more frequent auditing of applicable procedures), whether other corrective and monitoring activities are appropriate.