The Laws Nursing Facilities Must Comply With As Part of Your Compliance Program
In prior sections of this compliance guidance, we’ve compared setting up and maintaining a compliance program to building a house. We talked about how you have to first have blueprints and plans to build a house, and then a team of professionals to carry out those plans. We’ve talked about needing periodic inspections of the structure to make sure it’s working and plans for repairs and upgrades when needed. We’ve distinguished these “process” or “mechanical” aspects of a house from the interior of the house – the furnishings and appliances that go into the structure to make it a home.
Comparing these concepts to compliance programs, in prior sections of this compliance guidance, we’ve focused on the mechanical or process parts of a compliance program. We’ve discussed the need for a compliance officer and compliance committee, auditing and monitoring systems to make sure the compliance program is working properly, training for all employees to ensure they understand how the program works and what it requires of them, reporting systems for employees to ask compliance questions or report suspected compliance violations, and other process parts of a compliance program.
With these systems properly in place, we’re now ready to talk about the “furniture” of your compliance house – the federal laws with which all nursing facilities must comply and with make up the substance of a compliance program which all the other “process” parts are designed to reflect and monitor to ensure compliance. In the remaining parts of this compliance guidance, we examine the primary federal laws which should be a critical part of your compliance program in terms of ensuring that all employees, at all levels, and all contractors understand and comply with them.
In setting up your compliance program and teaching it to all employees and contractors, it really helps to think of the program in two chunks, as we’ve discussed in this compliance guidance: 1) the laws with which you must comply and 2) the systems built within your organization to ensure that all employees and contractors understand those laws, how to comply with them, and how to participate in your compliance program in terms of education about the compliance program and reporting and monitoring your facility’s compliance.