The deadline for having your compliance plan in place is rapidly approaching on March 13, 2013. Having a compliance plan in place will be of no real benefit if you are not focusing on effectiveness.
As part of the compliance program enforcement under the Affordable Care Act (ACA) starting in March of 2013, the Office of the Inspector General (OIG) and The Center for Medicare Services (CMS) state that a reliable audit and monitoring system are key elements to a effective compliance program. These auditing and monitoring functions need to cover all aspects of facility operations from financial to resident care. There is nothing difficult about auditing and monitoring, you already do it at some level each day when you check the nurses arriving for work (minimum staffing levels) or when the Laundry counts sheets ( part of the quality of care).
When using the words audit and monitoring along with a compliance program, the usual items that come to mind are the corporate business practices such as billing, trust funds and accounts receivables. These business practices are always supported by appropriate documentation. But these compliance practices must also include the entire array of care delivery and quality of care procedures nursing facilities undertake each and every day. The OIG has stressed both types of issues – finance/business operations and quality of care in its 2008 Compliance Guidance for Nursing Facilities.
Auditing and monitoring simply means having a reliable, periodic system to “audit” or check up on various aspects of facility and corporate operations which are a part of your corporate compliance program. Many of these auditing requirements facilities already undertake, you just may not recognize them as such. One example is the federally mandated monthly and quarterly Pharmacy Review audit.
The simple keys to having meaningful auditing and monitoring are;
1) Workable system that is not overly complex and confusing.
2) Reliable and Accurate.
3) Specific on how the auditing process will work and who will be responsible for making sure it does.
4) Review of your auditing processes periodically to ensure that they are doing the job they were designed to do.
5) Team approach (a single person won’t be able to do the job). Making your financial officer your compliance auditor probably won’t work as they are already very busy and do not have the knowledge to assess quality of care issues.
6) Seniority, authority, knowledge and time to perform the audit.
There are many ways to design a system for auditing and monitoring your facilities operations and your compliance program. In each of these, there are basic elements that are inherent to both operations. These include;
1) Specifically target and identify what you are monitoring
- Given the number of business, quality assurance processes and compliance issues which may be the subject of internal or external auditing, the most important first step is to target and clearly identify what you are auditing in a particular process or procedure and why. If your audit and monitoring team doesn’t have clear direction about what they are looking for and at, the results will be reflected as disorganization, missed issues and ineffective auditing.
- o Take into account that your team’s auditing tasks are performed across many disciplines and departments in your facility and company. Match the team member to the department or process to be audited.
- o Understanding which of those departments, policies or procedures are the target of a specific auditing or monitoring task, and giving the “team” clear direction is a critical first step.
- For example, one of the “high risk” areas identified by the OIG, is Comprehensive Care Plans. These Care Plans are a focus of both the OIG and CMS. A failure to demonstrate an effective care planning process could be basis for fraud and abuse or a false claims action. Having a team member who knows nothing about resident care do the auditing would result in an inaccurate audit. Be sure to match the team member to the task. In the case of auditing care plans, The compliance team should be assessing the effectiveness of Care Plans in the following areas;
- o Does the care plan meet the need of the resident, including
- Medical , Nursing, Mental and Psychosocial needs
- o Does the care plan have
- Reasonable objectives based on current and on-going resident diagnosis
- Preferences, needs and goals
- Timelines that are reasonable and attainable
- o Is there supporting documentation to prove all of the above in the form of;
- Interdisciplinary Team meetings
- Minutes for the meetings signed by all required attendees
- Are there starting and stopping times documented in the minutes.
- Required Physician participation (in person, by phone)
- Documented Care Plan goals developed during the meeting
- Are the goals specific, detailed, and understandable, and include time frames and expected outcomes.
- Do the IDT members frequently miss meetings
- Is the resident’s family encouraged to provide input
- Is Direct Care Staff participating in the IDT
- o Does the care plan meet the need of the resident, including
Targeting and clearly identifying each task to be audited and the steps to be taken is the key to making compliance painless.
2) Design the specific steps that make up the monitoring process for each specific issue or task needed.
- What source of information or process do you need as part of your audit process.
- o For example, will you be interviewing nursing staff about a specific care issue that has come to your attention through complaints, observations by management or nursing staff, survey results, quality indicator scores, or other sources? If so, which staff and how many will you interview?
- o Will you be reviewing resident charts and, if so, how many (what is a reliable sampling)?
- o Will you be reviewing billed claims and , if so, how many?
- Who does the compliance team report to and in what format?
- o Who does the compliance team submit the reports to? Remember this may include both internal reporting to company officials and external reporting if required under state and federal reporting requirements.
- o Written reports
- o Oral reports
- How frequently will you perform the audit and monitoring process?
- o Is the audit for review of medication error rates because your error rates have spiked? For this type of issue, perhaps a time-limited, focused review of medication processes, followed by a less frequent, but periodic, review to make sure any corrections implemented are working.
- o The results of your auditing and monitoring will normally suggest the appropriate frequency for auditing specific issues. If your audit results show noncompliance with facility/company policies and/or applicable law, this will be an indicator to you that you need to increase the audit frequency. This will be driven in part by the frequency of error rates your audits identify and the magnitude of noncompliance.
Compliance and auditing may seem to be daunting task especially to the small provider. But these tasks can be done easily if each audit task is clearly identified and the procedure for each audit task is specific and detailed. Knowing the requirements for compliance and for what the OIG and CMS will be specifically assessing will be key in developing your compliance audit list. Don’t wait for a bad survey to find out you are out of compliance. That can be a very expensive way to find out you are not in compliance.
Although CMS has not yet met the their deadlines for the QAPI for nursing facilities, the deadline of March 31, 2013 will most likely be enforced. The OIG and CMS has identified high risk areas that must be addressed by each organization. These areas will be under very specific scrutiny and facilities must have clear and documented auditing procedures to address each area. CMS has issued the “5 elements of QAPI” that nursing facilities will be held to. The high risk areas identified by the OIG are (but not limited to);
- Federal Anti-Kickback Statute
- Resident Safety
- Reserved Bed Arrangements and Payments
- HIPAA – Privacy and Security
- HITECH Act – Privacy and Security
- Sufficient Staffing
- Proper Reporting of Case Mix
- Use of Psychotropic Medicines
- Restorative/Personal Care Services
- Comprehensive Care Plans
- Medication Management
- Anti-Supplementation
- Therapy Services
- Physician Self-Referral (Stark Law)
- Hospice
Garlo Ward can help you with your compliance plan.
