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 https://oig.hhs.gov/compliance/self-disclosure-info/protocol.asp.