We’ve talked in earlier sections of this Compliance Guidance about the “house” portion of a compliance program, or the mechanical aspects of the program that make it operate. This includes the Corporate Philosophy Statement, Compliance Officer, and Compliance Committee, among others. It also includes mechanisms for reporting program violations, evaluating the success of the compliance program, internal auditing and monitoring mechanisms to detect compliance issues, and similar processes that we’ll discuss in later sections of this compliance guidance. All of these are mechanisms or processes that make the compliance program operate.
We also talked about the “furniture” part of a compliance program, or the substance that comprises the real content of the compliance program. This includes an explanation of the laws with which providers are required to comply (including laws governing financial transactions, quality of care, and other aspects of facility operation, among others) and a provider’s policies explaining how they implement and honor those laws.
Because nursing facility providers are subject to a large variety and number of laws, this part of a compliance program can be technical (for example, explaining the federal Anti-Kickback Statute), complex and lengthy. So, the challenge for providers is how to translate these laws and policies into something that is manageable and understandable by employees at all levels.
To accomplish this, providers should develop Employee Standards and a Code of Conduct which is like a “Readers’ Digest” summary of the longer, more detailed summaries of law and policies contained in the compliance program. This document is the primary tool which informs employees of the facility’s expectations regarding compliance issues. The Employee Standards and Code of Conduct should summarize the basic principles and policies of the compliance program and teach employees how to raise questions about the law, company policy or program operation, as well as how to report workplace practices that may violate the law or company policy. In most cases, this is the only document that will be routinely given to employees, although all employees should have access to the larger, more detailed written compliance program and be encouraged to review it.
The Employee Standards and Code of Conduct should be concise (some providers feel it should be no more than two to three pages long, but each provider has to decide what works best for their facility and employees), easily readable, and contain general principles. It may also include examples of practices that may violate applicable law or policy to help illustrate potential problems. In addition to the essential list of substantive “do’s and don’ts” for employees, it should also include the name or position of the individual employees should contact with compliance questions and to whom employees should report alleged or suspected violations of applicable law, company policy and/or the compliance program.
The risk areas which providers should address in their compliance programs, and from which the Employee Standards and Code of Conduct should be developed, will be discussed later in this compliance guidance. We will also provide a sample Employee Standards and Code of Conduct later in this compliance guidance.