If you hear the words “corporate compliance” and groan, “Oh no, not again,” you’re not alone. A lot has been written and said about NF corporate compliance since the OIG first published voluntary NF compliance guidance in March 2000. The discussion intensified in 2008 when the OIG released a supplement to its 2000 guidance and expanded the scope of the guidance, encouraging all long term care providers to establish and maintain effective compliance programs, with the goal to improve quality of care and services. And yet for many of you, corporate compliance remains a fuzzy concept surrounded by a maze of complicated laws, committees, audits and training.
Our goal in this NF compliance guidance is to change those “Oh no” moments to “Ah hah” moments.” We want you to hear “corporate compliance” and think “Hey, I’ve got this, I understand it, and I can do it.” We’re not saying that compliance is easy. It’s not. But it can be manageable. We’re also going to show how explaining compliance programs can be fun!
To do that, we’re going to compare NF compliance programs to something in the real world that everybody knows something about – houses. In this guidance, we’ve compared designing, building, maintaining and revising a NF compliance program to designing, building, maintaining and repairing a house. We know that many of you who are reading this guidance are the “teachers” in your company, and so we wanted to keep it as simple as possible. You may be the compliance officer, serve on the compliance committee or simply have a job that includes making sure your company has an effective compliance program, and you must ensure that all employees and contractors understand it and follow it.
We know from experience that one of the greatest obstacles to effective corporate compliance is company programs that are overly-complex, hard to understand and hard to manage. The OIG encourages all LTC providers, from multi-state companies to single-owner facilities, to have effective compliance programs, and expects all owners, managers and employees, from owners and Board members to front-line staff, to understand the program and participate in it actively. For that to happen, you have to know how to explain these programs in a way that everyone can understand.
The construction of any house begins with a planning and design process. So does an effective compliance program. We have described each step in the process so you can effectively navigate your way through the process:
- We begin with outlining why you need a compliance program, including the legal and practical benefits.
- We then explain what a compliance program looks like. It is helpful to think of compliance programs in two parts: 1) the physical structure that houses the program which includes compliance officers and committee, company policies and procedures that govern the operation of your compliance program, and other mechanics which make the program run; and 2) the “furniture” that goes in the “house,” aka the compliance structure, once it’s built. This “furniture” is usually expressed in terms of Employee Standards and Codes of Conduct, which summarize applicable laws and company policies and procedures that all employees and owners are expected to follow.
- Once your “house” is standing and fully equipped – you have to train everyone on how to use the appliances and other features. So, we will then discuss expected training for owners, Boards of Directors, employees and contractors.
- Every house has problems now and then so a process for spotting those problems and trying to prevent them in advance is essential. We talk about mechanisms for employees and others to report violations of your compliance program and provider self-inspections that detect and correct compliance violations.
- Ever discipline your child for breaking house rules? Well, likewise, every good compliance program needs a system for dealing with employees who violate your compliance program, and so, we discuss employee discipline as an element of compliance programs.
- Even the best home needs to be monitored for roof repairs or gas leaks. Likewise, a compliance program must include periodic reviews to spot problems or opportunities for improvement.
- Finally, we circle back and talk about the aforementioned “furniture,” which are the Employee Standards and Codes of Conduct that summarize the applicable laws and company policies and procedures that all employees and owners are expected to follow.
We will address all the following compliance concepts in the following sections of this web-based compliance guidance. We also will discuss each of these concepts in follow-up webinars:
- Building Tools - Terms You Need To Know
- The Basics - What is a Compliance Program and Why Do You Need One?
- Building Your Compliance Program - The Elements of an Effective Compliance Program
- Getting Started
- A Special Note on the Board of Directors and/or Owners
- “I Promise to Build You a Quality House” – Corporate Philosophy Statements
- The Architect and General Contractor – Appointing a Compliance Officer
- The Building Crew – Your Compliance Committee
- Developing Effective Lines of Communication
- Creation and Retention of Records
- Conducting Effective Training and Education\
- Compliance as an Element of Employee Performance
- Enforcing Standards Through Well-Publicized Disciplinary Guidelines
- Internal Auditing and Monitoring
- Responding to Detected Offenses and Developing Corrective Action Initiatives
- Assessing Effectiveness of a Compliance Program
- Risk Area Policies and Procedures
To make this compliance guidance user friendly, we have sample language for your use as you develop or revise your current compliance program, which you should modify to fit the unique nature of your company. When you see words in brackets [ ], fill in the bracket with the appropriate information for your company. In some cases, you’ll fill in your company or facility name. In others, you may choose between “Board of Directors” or “Owners,” for example, or select from other options we’ve suggested as possible language. You may also choose to take a totally different approach. There is no one way, and no right way or wrong way, to design and operate your compliance program. The key is to design a program that contains at least the basic elements, which the OIG believes are essential to any effective compliance program, and that work for your company or facility