Getting Compliance Right: Reporting and Response Protocols

Getting Compliance Right: Reporting and Response Protocols

Skilled nursing facilities (SNFs) receiving federal funds are obligated to adhere to all legal and ethical standards. Making sure that the correct reporting and response protocols are in place is the third step in meeting this demand for compliance.

A proper reporting, or disclosure, system must be accessible to all persons associated with the facility. All employees must be made aware that reporting actual or potential compliance violations is mandatory for continued employment, and not voluntary. This means that staff, or anyone involved in operating or helping the SNF, are under a legal obligation to report anything that is, or appears to be, a violation of law, rule, regulation, and company policy. This also means that an individual must make a report even if they were personally involved in the activity in question, as this is the best and only way to potentially avoid serious personal consequences. Needless to say, an attempt to prevent reporting by any other persons should be reported too, as that also constitutes a serious offence.

Staff observing potentially suspect activity are obligated to report their concerns in person, by phone, or in writing to a direct supervisor, department manager, the compliance officer, or the administrator. A supervisor who receives a compliance issue report is obligated to notify the company’s compliance officer as soon as possible. In this regard, the report can include the reporter’s name or it can be submitted anonymously. Another reporting mechanism is the use of a hotline, available 24 hours/7 days a week. Calls to the hotline can include the reporter’s name, or can be made anonymously as circumstances demand.

Once a report has been made, action must be taken according to established response protocols. These should include the following requirements:

– All reports have to be taken seriously and investigated, taking note of any demands for confidentiality—subject to legal enforcement demands.

– Any investigation must be completed by the compliance officer and/or designated members of the compliance committee within 30 days following reasonable suspicion of a violation.

– Person(s) involved or having knowledge of potential noncompliance will be interviewed by the compliance officer.

– Interviewees with relevant information may be required to submit a signed, dated, written statement.

– If the interviewee is not requested to submit a written statement, the compliance officer will document the interview and sign and date the record.

The compliance officer will have to conduct the interviews, review all documentation, study the relevant statutes, regulations, and company policies, and organize an internal oversight committee.

The compliance officer is required to make a final report to the compliance committee on the matter, which must include a corrective action plan. This plan must identify the nature of noncompliance and the immediate correction of any harm resulting from the violation. It should also indicate how the problem or problems were resolved.

Additionally, there are legally-mandated reporting guidelines with deadlines and detailed procedures. When an SNF finds that it needs to self-report a violation of a law, rule, or regulation, the Office of Inspector General (OIG) Provider Self-Disclosure Protocol should be used, which is available at

California Nursing Home Sued for Injury to Former Resident’s Eye

Healthcare Compliance Perspective:

Individual occurrences, in an of themselves, are compliance exposures, however repeated occurrences based on systemic issues may raise the potential for fraud allegations and potential compliance liability.

Alleging that a nursing home was responsible for elder abuse, negligent hiring and supervision and assault, a former resident has filed suit in Fresno County Superior Court. The former resident contends that he had to have his right eye surgically removed after being attacked by his roommate not once but twice. He further contends that after the first attack by his roommate, the nursing home staff did not intervene and prevent further attacks from occurring.

The nursing home claims that it “provides nothing short of stellar care and is a local leader in the industry.” The lawyer for the nursing home calls the lawsuit “another ‘shakedown’ type of lawsuit” due to what he termed “false advertisements” that the plaintiffs lawyer placed on social media as a way of getting additional clients to sue.

The lawsuit claims that the nursing home is understaffed, and its history supports the allegations in the suit. The nursing home has received 45 visits from the California Department of Social Services (CDSS) since 2013. These visits have included 12 Type A Citations and 16 Type B Citations. According to the CDSS, Type A Citations are issued for “the most serious type of violations in which there is an immediate risk to the health, safety or personal rights of those in care. Examples may include lack of care or supervision, access to open bodies of water, lack of a fire clearance for the building and access to dangerous chemicals. Citations for these violations will always be issued even if the violation is corrected on the spot.” A Type B citation is issued for “a violation that, if not corrected, may be an immediate risk to the health, safety or personal rights of clients. Examples include faulty medical record keeping and lack of adequate staff training.

The plaintiff’s attorney has been sent a letter requesting that the social media posts be removed and that the attorney stop running “improper ads” regarding the nursing home.

3 New Cases of Legionnaires at Illinois Veterans’ Home

Healthcare Compliance Perspective:

An effective Compliance and Ethics Program requires a good faith effort to detect and prevent fraud, waste and abuse.

Since 2015, a Western Illinois veteran’s home has been plagued with Legionnaires’ disease-13 deaths and dozens more have become ill. Recently, three new cases have been confirmed through laboratory tests. Fortunately, these residents seem to be recovering. The legionella bacteria causes a serious form of pneumonia that is contracted by inhaling infected water vapor.

The state is taking steps to boost the home’s water disinfection process hoping to reduce exposure and prevent more cases. Additionally, to reduce aeration from water vapor which is how the disease is spread, the state is placing new water filters on sinks and residents are only allowed to take showers-no tub baths. Staff are monitoring residents by taking their temperatures every two hours when the residents are awake.

Teams from the Centers for Disease Control and Prevention (CDC) have been at the facility working to find the potential sources for the legionella bacteria along with performing environmental tests. Earlier, the CDC reported that it is unlikely that the bacteria can be “completely eliminated” from the veterans’ home. Families of 11 stricken veterans have filed a lawsuit against the state.

Woman Found Dead Inside Speedway Nursing Home Leads to Licensing Complaint

Healthcare Compliance Perspective:

A licensed healthcare professional is responsible, not only for her own actions, but also for the actions of others acting under the healthcare professional’s license.

Last September, a 45-year-old woman was found dead in a Speedway nursing home, and it was evident due to the presence of insects on her body that she had been deceased for some time. The facility was closed about two months later.

An investigation by the Indiana Attorney General’s office revealed that the facility had been operating under the Health Facility Administrator’s (HFA) license of the former administrator for the facility. The former administrator stopped working at the facility in early 2015, but she allowed her license to continue to be used in order for the facility to remain open. The facility’s owner did not employ another administrator after the previous administrator whose license was being used left the facility’s employ.

When the facility was closed, there were 30 residents that the police relocated to other facilities.

The former administrator has been accused by prosecutors of fraud and failure to ensure that the residents of the facility were receiving proper care, and complaints of misuse of a license were made to the Health Facility Administration. A month earlier, the State Department of Health inspected the facility and found the facility in deplorable condition with multiple bugs crawling on the bathroom counter/sink, the entry rug, near the ceiling and above the facility’s entry door.

A hearing regarding the woman’s license has been set for March 27, 2018.

Cousins Committing $2.6 Million in Healthcare Fraud Get Suspended

Healthcare Compliance Perspective:

An effective Compliance and Ethics Program requires a good faith effort to detect and prevent fraud, waste and abuse.

Cousins who are not only are related to each other, they also admitted they were involved together in a nearly 3-year-long $2.6 million Medicare and Medicaid fraud involving two Hialeah pharmacies. Last month the Florida DOH ordered an emergency suspension applied to the cousins. Last year, the cousins each pleaded guilty to charges of conspiracy and committing wire and healthcare fraud.

The cousins will not be together while they are incarcerated. One will be at FCI Coleman until the end of March 2020, and the other will be serving time in a minimum security federal prison camp in Alderson, West Virginia until January 2019.

One of the cousins worked for the other who was the owner of the pharmacies involved. The healthcare fraud they perpetrated involved paying cash kickbacks to Medicare and Medicaid patients to use their identification numbers. The pair would then submit claims for reimbursement of prescription drugs and other healthcare items that the pharmacies had not provided.

Ironically, while both cousins defrauded the government out of $2.6 million, both cousins were involved in bankruptcy filings-one filed Chapter 13 bankruptcy which was dismissed due to failure to file information in 2015, but the other filed Chapter 7 bankruptcy claiming she had a monthly salary of $1,733.33, $263 in food stamps and $100 from family members. She also claimed that all she had in her wallet was $10 and only $200 in the bank. The court then discharged her $49,194 in credit card debt without payment.

Navigating Alternative payment models (APM) and the Data in 2018 for Home Care Agencies:

By ShirleyAnn Janulewicz RN, BSN, PHN

Competing in today’s healthcare market takes strategy and expertise. The Centers for Medicare and Medicaid (CMS) want to improve the patient care experience, improve the patients’ overall health, and they want to decrease the cost of care. Preventing re-hospitalization plays a major role.

When discharged, a patient may go to their former place of residence with home health to follow up, to a skilled nursing facility, or to an in-patient rehab center. Since hospitals bears the burden of risk in regards to the money they will receive from CMS in caring for that patient, they want to utilize the services that show the best stewardship of that money. They look at the data produced showing who provided the best care with the best outcomes for the least amount of money. Some of the data they use is data that is available to the consumer, such as Home Health Compare and the STAR ratings.

Home care agencies need to know how to utilize this data so they can determine their standing among their peers. They need to evaluate where they can improve their plans of care to achieve their best possible outcomes without the patient needing to be re-hospitalized.

By utilizing charts and graphs to compare this data, the home care agency can better understand the many factors involved. It may seem intimidating and challenging to those who are resistant to change; however, by taking the time to assimilate and understand data-driven care, we can better promote our strengths and work on our weaknesses to become a viable discharge alternative in the ever-changing healthcare environment.

Wisconsin Nursing Homes Close as Costs Rise and Reimbursement Rates Can’t Keep Up

Healthcare Compliance Perspective:

In situations of financial distress, it is important to remember that creative marketing strategies which target Medicare beneficiaries or providers, create risk of violating the Federal Anti-Kickback Statute. The Anti-Kickback Statute prohibits offering to pay remuneration of any kind in exchange for referrals.

Medicaid reimbursement rates that are not keeping up with the costs involved in providing care may be the reason for the growing number of Wisconsin nursing home closures according to some nursing home providers. The Wisconsin Department of Health Services (WDHS) recently reported that ten, long-term care facilities closed in 2017 compared with six that closed in 2016.

The executive director for the Wisconsin Health Care Association says that an average long-term care facility experiences a loss of about $1 million per year in connection to the Medicaid residents they serve. Specifically, nursing homes in Douglas County lost $2.3 million and the only nursing home in Bayfield County lost $811,00 from 2015 to 2016.

While the Bayfield County Administrator indicated that providers would like a 5 percent increase in the reimbursement rate, the current state budget will be increasing the reimbursement rate for skilled nursing facilities by 2 percent annually. Providers are worried that a growing population and lower reimbursements together are cause for concern that more nursing homes will be closing. In addition to the losses being experienced, the reimbursement rates are making it harder for facilities to find and retain workers. One industry survey taken in 2016 of almost 690 providers across the state found “11,500 unfilled caregiver positions.” Providers are finding it difficult to compete with the wages paid by convenience stores, big box retailers and fast food services.

The WDHS has initiated what it calls, “the WisCare Caregiver Career Program” in response to the shortage of Certified Nurse Aides (CNAs), and involves an investment of $2.3 million to help providers attract and retain about 3,000 CNAs.

Getting Compliance Right: Training and Auditing

Skilled nursing facilities (SNFs) receiving federal funds are obligated to adhere to all legal and ethical standards. Making sure that the correct training and auditing policies are in place is the second step in meeting this demand for compliance.

When dealing with the training aspect, it should be stressed that employee participation at all levels must be mandatory because compliance is everyone’s responsibility—and any failures in this regard will impact everyone at the facility. For this reason, SNF management must ensure that a full explanation of the compliance program and all regulatory issues is provided to employees, executives, governing body members/owners, board members, and all other persons associated with the facility, including vendors, consultants, residents, and family members.

A properly constituted compliance training program should include:

• A compliance plan, including a code of conduct,
• New hire orientation, including compliance expectations, and
• Regular compliance training, at least on an annual basis and more often if required.

It is equally important to remember to document all information presented, and ensure that all attendees are noted, including dates of training, so that no one can later say they did not know.

The auditing and monitoring part of compliance entails the identification of compliance risk areas, and a concomitant self-evaluation of risk areas. These risk areas should be identified as those most vulnerable to any compliance issue—in other words, to preempt any criminal, civil, and administrative violations. In order for this to be done, a structure has to be in place to collect and analyze data which assesses the facility’s compliance with established standards of practice. Examples of the sort of areas which need special attention in this regard include, but are not limited to, quality control, documentation, billing, and reimbursement guidelines.

The process of internal auditing should take the form of regular interviews with management personnel regarding compliance within their departments, questionnaires to be filled out by staff on compliance matters and the effectiveness of training techniques, written reports from management using predefined assessment tools, and external audits.

Elopement Assessment After Hospitalization

A resident was readmitted from the hospital, and staff did not check his prior care plan and assessments for risk of elopement and behavior issues. The 91-year-old dementia resident who had lived in the facility for 10 months was found wandering in the main lobby. The staff member took the resident back to his unit. The staff on the resident’s floor were surprised and were not aware that he had wandered off their unit. The resident had previously worn a WanderGuard, but he did not have one reapplied when he returned from the hospital.

Elopement and unsafe wandering continue to be high-risk resident safety issues. When developing systems to prevent elopement and unsafe wandering, there are many components. One area that can be overlooked is how to address residents who are sent to the hospital and return. Residents with a history of unsafe wandering or who are identified at risk for elopement wear an “alert bracelet” (Example brand names: WanderGuard, Secure Care) that prevents the resident from leaving the place where he or she lives without appropriate supervision. At times of transfer to a hospital, these alert bracelets are removed. A standard practice to ensure a resident receives the appropriate interventions to address the risk of elopement and unsafe wandering is assessment of all residents immediately upon return from a hospital. This practice requires implementation of a clear process with specific personnel identified to complete the assessment. Once the role and responsibility of who performs the assessment is identified, training should occur on how and when to complete the assessment. We all know residents can return at any time to the facility from the hospital. This risk assessment should happen immediately upon the resident’s return. A monitoring/auditing process should be implemented to ensure the risk assessment was completed on time and is accurate, the appropriate follow up of placing an alert bracelet was completed, staff were notified, and care plan updates were completed. Report the results to the QAPI committee to determine if any further actions are needed.

Implementing a consistent practice of assessing all residents’ risk related to elopement and unsafe wandering upon return from a hospital reduces the risk of overlooking application of a bracelet for a returning resident who previously wore one for safety.

Resident’s Death Raises Alarm About Security

Healthcare Compliance Perspective:

It is essential to develop elopement risk prevention procedures which include but are not limited to: elopement risk assessments administered upon admission, elopement risk assessments administered periodically or upon realistic concern that a resident has become an elopement risk, and/or development and implementation of elopement prevention plan which is then integrated into resident care. Compliance Officers should confer with the Quality Assurance Performance Committee to ensure that elopement risk prevention is an active part of resident care.

After receiving four citations from the Wisconsin Department of Health Services (WDHS) a Wisconsin assisted living facility reached the deadline that was given to them to file an appeal. When contacted by the news media, the facility was not forthcoming with any plans to appeal; consequently, under the terms of the Notice of Violation, the facility is not allowed to accept new residents and must pay a $4,200 assessment.

The incident causing the security concern involved an 84-year-old resident with dementia, who was previously identified as being at risk for elopement, and who was found dead outside of the facility last December due to hypothermia. The resident’s family reported that it was the facility’s marketing and promotion of providing special care for persons with dementia that caused them to relocate the woman from the “traditional nursing home” she was at to the facility in question.

The WDHS documented that the assisted living facility had records indicating that the woman had wandered through the facility and that they realized she was a risk for elopement. Yet, on the night she eloped from the facility, the doors were propped open and no alarms were activated.

An advocate from the Alzheimer’s and Dementia Alliance of Wisconsin, reported that “the state does not have concrete requirements for differences in practices at assisted living facilities that specialize in dementia.” He also suggested that if a facility says it “provides specialized care for people with dementia” there is an expectation that the facility will provide that specialized care. Another part of the problem in this case he pointed out is that the state does not have stated requirements for what that specialized care is. However, the advocate pointed out that there should be security for the residents in any assisted living facility-doors with alarms need to be monitored and when an alarm goes off it must be checked.

Another aspect being taken into consideration is that this facility has had numerous violations from early 2016 to this recent notice of violation.