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1. CAHSA MAKING LEMONADE FROM LEMONS: Developing an Effective Corporate Compliance Program For the Senior Housing Industry Cheryl Dillon, RNC, BSN, LNHA Chief Clinical Officer, Upstairs Solutions

2. Let’s begin at the end Numbers of courses watched- 19,242 Number of exclusion checks ran- 24,332 Number of days in CIA – 1825 Number of pounds gained- 23 Number of manic moments- ENDLESS

3. Who is ABS Management? Third Generation Nursing Home Operators Facilities 49 - 125 beds Primarily rural “Typical” regulatory history “Corporate” Structure 1616 days ago I became a proud owner of a CIA -209 to go Third-Generation Nursing home provider- my grandparents walk the halls of the facilties until today. Never had any major Public Health issues. Typical Provider- several small facilities ranging from 49- 149 beds. Most of the facilities are in rural areas with a limited referal base. Small town feel- one of our facilties can barely be seen during corn harvest time because it is literally in a corn field! Had a good reputation in the industry. We were very involved owners but didn’t have any compliance program or true system of checks and balances Bottom line: If it could happen to me, it could happen to anyone! 1616 days ago I became a proud owner of a CIA -209 to go Third-Generation Nursing home provider- my grandparents walk the halls of the facilties until today. Never had any major Public Health issues. Typical Provider- several small facilities ranging from 49- 149 beds. Most of the facilities are in rural areas with a limited referal base. Small town feel- one of our facilties can barely be seen during corn harvest time because it is literally in a corn field! Had a good reputation in the industry. We were very involved owners but didn’t have any compliance program or true system of checks and balances Bottom line: If it could happen to me, it could happen to anyone!

4. So What Happened? Maxwell Manor Management contract Improvements Disgruntled Employee Federal Survey 13 IJ’s Subpoenas flying In late 1998 we were approached to manage a facility in Chicago. Facility had a young population, located in inner city chicago with primarily psychiatric diagnosis. Together with our attorneys we established a separate management company and management team. Facility was reputed as being a hell hole and even the Fedex refused to bring packages. I had concerns about management of this building from minute one but was reassured by our attorneys that it was a management contract, and we have a good reputation with the state. We actually met with state before taking it over and had further reassurances. We did significant rehab but do to the nature of the clientele, you were taking one step forward and 2 step backwards.it was a seven story dinasour of a building. Public health surveys were getting significantly better, and public health acknowledged improvements. slow and steady. We only had the building for a total of 18 months Had share of disgruntled employees..we all do. In May of 2000 received a call that 7 federal surveyors came in the building and within hours subpoenas were flying in our office. Received 13 immediate jeopardies. Spend the 3 weeks living in the building, hiring private security doing everything we knew how. We let the owners know that we intend to get through the revisit but we wanted to immediately step out of the management contract. By June we were out of the management and soon after the building was shut downIn late 1998 we were approached to manage a facility in Chicago. Facility had a young population, located in inner city chicago with primarily psychiatric diagnosis. Together with our attorneys we established a separate management company and management team. Facility was reputed as being a hell hole and even the Fedex refused to bring packages. I had concerns about management of this building from minute one but was reassured by our attorneys that it was a management contract, and we have a good reputation with the state. We actually met with state before taking it over and had further reassurances. We did significant rehab but do to the nature of the clientele, you were taking one step forward and 2 step backwards.it was a seven story dinasour of a building. Public health surveys were getting significantly better, and public health acknowledged improvements. slow and steady. We only had the building for a total of 18 months Had share of disgruntled employees..we all do. In May of 2000 received a call that 7 federal surveyors came in the building and within hours subpoenas were flying in our office. Received 13 immediate jeopardies. Spend the 3 weeks living in the building, hiring private security doing everything we knew how. We let the owners know that we intend to get through the revisit but we wanted to immediately step out of the management contract. By June we were out of the management and soon after the building was shut down

5. False Claims Act Thank you President Lincoln! False Claims Act and LTC Qui Tam Relator (Whistleblower) Settlement Monetary settlement CIA 1)In 1863, at the height of the Civil War , President Abraham Lincoln urged Congress to adopt a law that would rein in rampant war profiteering among suppliers to the Union Army. Lawmakers responded by passing the False Claims act, also known as Lincoln Law,” allowing private citizens to sue those who bilked the government 2) In 1996 the united states filed a lawsuit against a nursing home that is it alleged was providing inadequate nutrition and woundcare to residents, despite the fact that the facility had submitted claims to Medicare and medicaid for payment for nutritional service. The theory is simple: Medicare and medicaid provider certification agreements require compliance with all federal and state laws applicable to the services provided. Submitting claims for reimbursement while providing inadequate care and thus, failing to comply with the extensive nursing home quality of care federal and state laws, constitutes fraud on the government. 3) The Qui-tam relator –facility program coordinator who was fired in July 1999 for not implementing programs and following up on abuse allegations- The case began in February 2000, Federal survey in May 2000 we received the actual suit brought aginst us in March of 2004. From March 2004 until November 2004 we negotiated the monetary settlement and the terms of the CIA Settlement: Avoid the cost of defending ourselves against fraud charges 1)In 1863, at the height of the Civil War , President Abraham Lincoln urged Congress to adopt a law that would rein in rampant war profiteering among suppliers to the Union Army. Lawmakers responded by passing the False Claims act, also known as Lincoln Law,” allowing private citizens to sue those who bilked the government 2) In 1996 the united states filed a lawsuit against a nursing home that is it alleged was providing inadequate nutrition and woundcare to residents, despite the fact that the facility had submitted claims to Medicare and medicaid for payment for nutritional service. The theory is simple: Medicare and medicaid provider certification agreements require compliance with all federal and state laws applicable to the services provided. Submitting claims for reimbursement while providing inadequate care and thus, failing to comply with the extensive nursing home quality of care federal and state laws, constitutes fraud on the government. 3) The Qui-tam relator –facility program coordinator who was fired in July 1999 for not implementing programs and following up on abuse allegations- The case began in February 2000, Federal survey in May 2000 we received the actual suit brought aginst us in March of 2004. From March 2004 until November 2004 we negotiated the monetary settlement and the terms of the CIA Settlement: Avoid the cost of defending ourselves against fraud charges

6. What is a CIA? Does not replace CMS and state survey agency functions Focus is on systemic issues not individual problems Internal systems of QA Unlike CMS, the OIG can cross state lines Chain-wide perspective, can look at all facilities in an organization A CIA and monitor visit does not replace the survey- its in addition to the survey. In fact, an independent monitor is mandated to report serious concerns to the hotline. CMS and state surveys get a snap shot of a facility on a given day. CIA looks at provider over course of time during the life of CIA. CMS and state surveys look at care provided to particular individual residents. While the CIA care about individuals, the focus of the CIAs is on systemic issues and the provider’s internal system of addressing those issues. When we find individual care problems at facilities, we refer them to the surveyors. Another example, due to the structure of CMS survey and enforcement rules, it is often easy for facility to evade remedies. When the surveyors cite a facility with deficiencies, the facility can simply submit a POC and get back into compliance with regs, but then slip back into poor care til the next annual survey. This is refered to as Yo Yo compliance (up and down in performance). CMS often wants the OIG help in severe and needs the OIG in these cases to let the provider know it can’t evade government scrutiny. . There are legal and practical limits to what CMS remedies can do. For example, CMS remedies only apply to the single facility being surveyed, not corporate management. So if problems are caused by corporate management failing to provide needed resources, CMS cannot take action against management. OIG can. They can look at the patterns of a management company across the country and arent limited to a single state or area. A CIA and monitor visit does not replace the survey- its in addition to the survey. In fact, an independent monitor is mandated to report serious concerns to the hotline. CMS and state surveys get a snap shot of a facility on a given day. CIA looks at provider over course of time during the life of CIA. CMS and state surveys look at care provided to particular individual residents. While the CIA care about individuals, the focus of the CIAs is on systemic issues and the provider’s internal system of addressing those issues. When we find individual care problems at facilities, we refer them to the surveyors. Another example, due to the structure of CMS survey and enforcement rules, it is often easy for facility to evade remedies. When the surveyors cite a facility with deficiencies, the facility can simply submit a POC and get back into compliance with regs, but then slip back into poor care til the next annual survey. This is refered to as Yo Yo compliance (up and down in performance). CMS often wants the OIG help in severe and needs the OIG in these cases to let the provider know it can’t evade government scrutiny. . There are legal and practical limits to what CMS remedies can do. For example, CMS remedies only apply to the single facility being surveyed, not corporate management. So if problems are caused by corporate management failing to provide needed resources, CMS cannot take action against management. OIG can. They can look at the patterns of a management company across the country and arent limited to a single state or area.

7. Corporate Integrity Agreement Release from Exclusion Quality of Care 5 year 8 key components The basis for most corporate integrity agreements lies in the governments statutory authority to exclude providers who violate Medicare law. For example if convicted of the a violation of the false claims act a medicare provider may be exclused from participating in the federal healthcare programs for 5 years. A CIA is a contract that imposes systems, monitoring and reporting requirements on providers. Since 2002, over 1300 health care facilities, mostly nursing homes, have operated for some period of time under a quality of care CIA. As of May 2008, the OIG has 11 cia’s with nursing homes and psychiatric facilites (or chains) with monitoring. These 11 cia’s cover operations in about 400 ltc facilites across the country. Our CIA did not have a financial component..strictly quality of care so there was no IRO involved. First Quality of Care in under the False claims act in IL 8 key components to all cia’sThe basis for most corporate integrity agreements lies in the governments statutory authority to exclude providers who violate Medicare law. For example if convicted of the a violation of the false claims act a medicare provider may be exclused from participating in the federal healthcare programs for 5 years. A CIA is a contract that imposes systems, monitoring and reporting requirements on providers. Since 2002, over 1300 health care facilities, mostly nursing homes, have operated for some period of time under a quality of care CIA. As of May 2008, the OIG has 11 cia’s with nursing homes and psychiatric facilites (or chains) with monitoring. These 11 cia’s cover operations in about 400 ltc facilites across the country. Our CIA did not have a financial component..strictly quality of care so there was no IRO involved. First Quality of Care in under the False claims act in IL 8 key components to all cia’s

8. Eight Components of a CIA Independent Monitor Compliance Officer Policy and Procedure Training Requirements Internal Audit Systems -An independent quality monitor authorized with unfettered access to facilties, staff, residents documents and management at every level of the organization Appointed by the OIG Key provision in all quality of care CIA’s- many CIA’s will also have an independent review organization (IRO) that will also audit financial Monitor has extensive powers of access to facilities, residents, staff, corporate management, and records Monitor plays consultative role Monitor not just a cop who plays “gotcha”; important consultative role. This is another big difference from CMS surveyors; they are not allowed to provide extensive consultation. Consultative role key to success of CIA. Easier to make progress if provider not resisting you every step of the way. We want provider to buy into the monitor concept and view monitor as a “value added” resource. Before we choose monitor, provider meets with the monitor to make sure comfortable. While consultative role important, bottom-line job of the monitor is to assess CIA compliance and let OIG know if problem arise. Consultant with teeth. If provider doesn’t do what consultant recommends, provider has to explain why not to OIG. A compliance officer who oversees all compliance systemsand coordinates with the OIG and the monitor 1)Make sure your corporate compliance officer is organized and will be respected by leadership. You are setting the tone from day 1 on how serious ownership takes this position and that is the attitude you want trickled down to staff 2)Make sure the staff really understands her role..it is not an anonymous person with some 800 number 3) In a small company like ours, we didn’t realize the challenges that the corporate compliance officer might have. Worked with her for many years before this position..she is autonomous, but your employee at the same time. Provided Tammy with access to council Policies and procedures with an interdisciplinary approach Competency based training requirements Interal audit functions that should continue beyond the CIA- This means a QA system that is meaningful and you have a system of checks and balances in your company that allow you to find your own problems and self correct- creat -An independent quality monitor authorized with unfettered access to facilties, staff, residents documents and management at every level of the organization Appointed by the OIG Key provision in all quality of care CIA’s- many CIA’s will also have an independent review organization (IRO) that will also audit financial Monitor has extensive powers of access to facilities, residents, staff, corporate management, and records Monitor plays consultative role Monitor not just a cop who plays “gotcha”; important consultative role. This is another big difference from CMS surveyors; they are not allowed to provide extensive consultation. Consultative role key to success of CIA. Easier to make progress if provider not resisting you every step of the way. We want provider to buy into the monitor concept and view monitor as a “value added” resource. Before we choose monitor, provider meets with the monitor to make sure comfortable. While consultative role important, bottom-line job of the monitor is to assess CIA compliance and let OIG know if problem arise. Consultant with teeth. If provider doesn’t do what consultant recommends, provider has to explain why not to OIG. A compliance officer who oversees all compliance systemsand coordinates with the OIG and the monitor 1)Make sure your corporate compliance officer is organized and will be respected by leadership. You are setting the tone from day 1 on how serious ownership takes this position and that is the attitude you want trickled down to staff 2)Make sure the staff really understands her role..it is not an anonymous person with some 800 number 3) In a small company like ours, we didn’t realize the challenges that the corporate compliance officer might have. Worked with her for many years before this position..she is autonomous, but your employee at the same time. Provided Tammy with access to council Policies and procedures with an interdisciplinary approach Competency based training requirements Interal audit functions that should continue beyond the CIA- This means a QA system that is meaningful and you have a system of checks and balances in your company that allow you to find your own problems and self correct- creat

9. Eight Components of a CIA Quality Assurance Committee Reporting System Reporting Certain events to the OIG A quality assurance committee including clinical leadership and compliance officer to oversee clinical improvement and compliance issues throughout the organization This is ex A system of reporting information within the organization without fear of retatliation such as a toll free anonymous hotline Requirements that an organization report certain events such as significant overpayments or serious quality of care problems to the OIG and federal monitors within specific timeframes A quality assurance committee including clinical leadership and compliance officer to oversee clinical improvement and compliance issues throughout the organization This is ex A system of reporting information within the organization without fear of retatliation such as a toll free anonymous hotline Requirements that an organization report certain events such as significant overpayments or serious quality of care problems to the OIG and federal monitors within specific timeframes

10. Monitors “Assistant U.S. Attorney Michele Fox said an independent monitor will oversee the other nursing homes ABS manages in Illinois. No dangers or deficiencies were found in those facilities, she said.” Chicago Sun-Times November 23 , 2004 Important quote. This is the underlying principle of the CIA. Although there were no issues with our other buildings, the belief of the OIG is there is systemic breakdown. There are legal and practical limits to what CMS remedies can do. For example, CMS remedies only apply to the single facility being surveyed, not corporate management. So if problems are caused by corporate management failing to provide needed resources, CMS cannot take action against management. OIG can. For this reason the OIG enforced monitoring in the other ABS facilites Important quote. This is the underlying principle of the CIA. Although there were no issues with our other buildings, the belief of the OIG is there is systemic breakdown. There are legal and practical limits to what CMS remedies can do. For example, CMS remedies only apply to the single facility being surveyed, not corporate management. So if problems are caused by corporate management failing to provide needed resources, CMS cannot take action against management. OIG can. For this reason the OIG enforced monitoring in the other ABS facilites

11. “It Can’t Happen to Me” “Most of us can read the writing on the wall but we believe it is addressed to someone else.” Ivern Ball yy

12. Now What???? Mandatory Compliance= March 26, 2013 So, what is a corporate compliance program? Simply stated, it is a written and operational commitment to organization-wide compliance with all applicable laws. This includes laws governing quality of care, like federal OBRA laws and regulations and state licensure laws, fraud and abuse-specific laws like the federal False Claims Act and Anti-Kickback Statute and a variety of other laws governing the delivery of care and claims for payment in NFs. 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 expects all owners, managers and employees, from owners and Board members to front-line staff, to understand the compliance program and participate in it actively. For that to happen, you have to know how to design, build and implement a compliance program; as well as understand the legal and practical benefits for implementing a program. So, what is a corporate compliance program? Simply stated, it is a written and operational commitment to organization-wide compliance with all applicable laws. This includes laws governing quality of care, like federal OBRA laws and regulations and state licensure laws, fraud and abuse-specific laws like the federal False Claims Act and Anti-Kickback Statute and a variety of other laws governing the delivery of care and claims for payment in NFs. 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 expects all owners, managers and employees, from owners and Board members to front-line staff, to understand the compliance program and participate in it actively. For that to happen, you have to know how to design, build and implement a compliance program; as well as understand the legal and practical benefits for implementing a program.

13. Why Do I Need One? Help Control Environment Keep out inclement elements Investment of time, energy, and money Return on investments Mandatory So, why do you need a compliance program? Well, why do you need a house? After all, you could live in a tree, or under a tent, instead of a house. It would be cheaper and a lot simpler. You wouldn’t have a mortgage or rent, no yard work, no utility bills. But, then, your quality of life would be driven by factors you can’t control, like the weather. Your house allows you to control the environment in which you live, at least to some degree. You can keep out the weather, monitor the kids, and decide who comes in and who stays out. Having a house, and that control, costs money and takes commitment and time. But, most of us think it’s worth it and, frankly, most of us don’t live in trees or tents. Compliance programs are the same. They help you control the environment in which your residents live and in which you work. They help you keep out inclement elements that reduce quality of care, create legal risks and liability, dishearten employees and, in the end, cost you money. Like a nice, secure house, compliance programs take investments of time, energy, and money, and sometimes require reallocation of resources. But, there are returns on those investments.  So, why do you need a compliance program? Well, why do you need a house? After all, you could live in a tree, or under a tent, instead of a house. It would be cheaper and a lot simpler. You wouldn’t have a mortgage or rent, no yard work, no utility bills. But, then, your quality of life would be driven by factors you can’t control, like the weather. Your house allows you to control the environment in which you live, at least to some degree. You can keep out the weather, monitor the kids, and decide who comes in and who stays out. Having a house, and that control, costs money and takes commitment and time. But, most of us think it’s worth it and, frankly, most of us don’t live in trees or tents. Compliance programs are the same. They help you control the environment in which your residents live and in which you work. They help you keep out inclement elements that reduce quality of care, create legal risks and liability, dishearten employees and, in the end, cost you money. Like a nice, secure house, compliance programs take investments of time, energy, and money, and sometimes require reallocation of resources. But, there are returns on those investments. 

14. How Do I Get Started?? OIG Recommendations for compliance and CIA’s 2008 Supplement to OIG Compliance Program Guidance for Nursing Facilities http://oig.hhs.gov/fraud/docs/complianceguidance/nhg_fr.pdf Where do you begin? Start like I did -- by carefully studying a corporate integrity agreement (hopefully not your own!). The OIG website posts all CIAs and they are an excellent reference tools to guide you in what your compliance program should look like. I would recommend routinely checking the OIG website (http://oig.hhs.gov/) for updates and recommendations, as well as the websites for the national associations[MPG1]  for their compliance program “how-to’s.”  Original guidance to providers was released in 2002- supplementatl guidance ws releasd in 2008. Some key points that were added in the supplemental guidance include -Where do you begin? Start like I did -- by carefully studying a corporate integrity agreement (hopefully not your own!). The OIG website posts all CIAs and they are an excellent reference tools to guide you in what your compliance program should look like. I would recommend routinely checking the OIG website (http://oig.hhs.gov/) for updates and recommendations, as well as the websites for the national associations[MPG1]  for their compliance program “how-to’s.”  Original guidance to providers was released in 2002- supplementatl guidance ws releasd in 2008. Some key points that were added in the supplemental guidance include -

15. It Starts at the Top Initiate a Culture of Compliance Corporate Accountability Board of Director Involvement www.oig.hhs.gov/fraud/docs/complianceguidance/Roundtable013007.pdf RISK AND COMPLIANCE IS A SALES JOB. YOU NEED TO SELL YOUR TEAM TO DO THE RIGHT THING A culture of compliance needs to be initiated from the top of the organization. A corporate compliance program is not a binder that sits on a shelf; it must be an engrained culture in an organization. Our CIA was quality care based, and oversight of our quality of care systems became the cornerstone of our compliance program. As owner and part of the Board of Directors, I let our staff clearly know that we were embracing our compliance plan and this is THE culture of our organization. As ownership, we became more involved in the quality assurance process, by actually participating in the QA meetings. I recently participated in a HCCA/OIG roundtable discussion about Dashboards for Quality of Care, and the panel agreed to that that whether you were an organization with 200 facilities or a single building operator, the concerns for monitoring quality of care were more or less the same [i] [i] “Government- Industry Roundtable, “Driving for Quality in Long-Term Care: A Board of Directors Dashboard” (PDF file), downloaded from OIG website, http://www.oig.hhs.gov/fraud/docs/complianceguidance/Roundtable013007.pdf, accessed January 2, 2010.RISK AND COMPLIANCE IS A SALES JOB. YOU NEED TO SELL YOUR TEAM TO DO THE RIGHT THING A culture of compliance needs to be initiated from the top of the organization. A corporate compliance program is not a binder that sits on a shelf; it must be an engrained culture in an organization. Our CIA was quality care based, and oversight of our quality of care systems became the cornerstone of our compliance program. As owner and part of the Board of Directors, I let our staff clearly know that we were embracing our compliance plan and this is THE culture of our organization. As ownership, we became more involved in the quality assurance process, by actually participating in the QA meetings. I recently participated in a HCCA/OIG roundtable discussion about Dashboards for Quality of Care, and the panel agreed to that that whether you were an organization with 200 facilities or a single building operator, the concerns for monitoring quality of care were more or less the same [i]

16. Corporate Compliance Officer and Compliance Committee Start Recruiting Today-Chose Carefully May Have Several Different Roles Give Autonomy Focus on Both Financial and Quality of Care Report to facilities owner, governing body and CEO Designation of a Compliance Officer and Compliance Committee. Just as a household needs someone in charge to manage operations, an effective compliance program must have a compliance officer and often a compliance committee who are responsible for developing, operating and monitoring the compliance program. They must report directly to the facility’s owner, its governing body, and CEO, periodically and on an as-needed basis. The compliance officer must oversee the program, including making revisions as the facility’s needs change, coordinating and participating in training and education for employees, independently investigating compliance matters and ensuring that any necessary corrective action is taken. Designation of a Compliance Officer and Compliance Committee. Just as a household needs someone in charge to manage operations, an effective compliance program must have a compliance officer and often a compliance committee who are responsible for developing, operating and monitoring the compliance program. They must report directly to the facility’s owner, its governing body, and CEO, periodically and on an as-needed basis. The compliance officer must oversee the program, including making revisions as the facility’s needs change, coordinating and participating in training and education for employees, independently investigating compliance matters and ensuring that any necessary corrective action is taken.

17. Develop Effective Lines of Communication Complaint Hotline Mechanism to Report Complaints/Grievances Without Retaliation 800 number Developing Effective Lines of Communication. It’s not enough to appoint a compliance officer and committee, even if they are diligent. As with any head of a household, the compliance officer must create and maintain effective lines of communication with all employees. This should include a process, such as a hotline or other reporting system, to encourage questions and complaints and procedures to protect the confidentiality or reports and anonymity of the complainants and to protect employees against retaliation. Developing Effective Lines of Communication. It’s not enough to appoint a compliance officer and committee, even if they are diligent. As with any head of a household, the compliance officer must create and maintain effective lines of communication with all employees. This should include a process, such as a hotline or other reporting system, to encourage questions and complaints and procedures to protect the confidentiality or reports and anonymity of the complainants and to protect employees against retaliation.

18. Creation and Retention of Records Medical record documentation Policies and Procedures Retention and destruction of records Privacy concerns Document and track Creation and Retention of Records. This essential part of a compliance program goes hand in hand with quality medical care and proper billing – developing and implementing a records system that ensures complete and accurate medical record documentation, including policies and procedures addressing documentation of services records, retention and destruction of records and privacy concerns. If problems arise, the facility must be able to demonstrate the integrity of the facility’s compliance process, its effectiveness, and the facility’s efforts to comply with all applicable statutes and regulations. This can only be accomplished by documenting every element of the program. Creation and Retention of Records. This essential part of a compliance program goes hand in hand with quality medical care and proper billing – developing and implementing a records system that ensures complete and accurate medical record documentation, including policies and procedures addressing documentation of services records, retention and destruction of records and privacy concerns. If problems arise, the facility must be able to demonstrate the integrity of the facility’s compliance process, its effectiveness, and the facility’s efforts to comply with all applicable statutes and regulations. This can only be accomplished by documenting every element of the program.

19. Effective Training and Education Fundamental Building Block Consistent Efficient Reliable Tracking Economical Standards of Conduct critical element of an effective compliance program is training the facility’s employees and contractors on the compliance program. This should include training on both the company’s compliance program itself (i.e., how the program operates, who is the compliance officer, etc.) and on the applicable laws and company policies that make up the compliance program. Conducting Effective Training and Education. If we want our kids to obey the rules of the house, we don’t merely write them a note -- we must educate them in ways consistent with their particular ages and learning styles. Similarly, a necessary component of an effective compliance program, according to the OIG, is the proper and periodic education and training of all managers, physicians and facility personnel at all levels. The facility should use a variety of teaching methods which take into account the skills and experience of the individual trainees. The content may vary according to the specific group being trained, but all must at a minimum understand the facility’s standards of conduct, compliance with Medicare requirements, proper documentation in clinical and financial records, and the prohibition on payment for referrals, residents’ rights, and the duty to report misconduct. critical element of an effective compliance program is training the facility’s employees and contractors on the compliance program. This should include training on both the company’s compliance program itself (i.e., how the program operates, who is the compliance officer, etc.) and on the applicable laws and company policies that make up the compliance program. Conducting Effective Training and Education. If we want our kids to obey the rules of the house, we don’t merely write them a note -- we must educate them in ways consistent with their particular ages and learning styles. Similarly, a necessary component of an effective compliance program, according to the OIG, is the proper and periodic education and training of all managers, physicians and facility personnel at all levels. The facility should use a variety of teaching methods which take into account the skills and experience of the individual trainees. The content may vary according to the specific group being trained, but all must at a minimum understand the facility’s standards of conduct, compliance with Medicare requirements, proper documentation in clinical and financial records, and the prohibition on payment for referrals, residents’ rights, and the duty to report misconduct.

20. Tackling the Training Developed online training and tracking system Nationally recognized training company Cheryl, CCO and myself sat down and carefully reviewed the training requirements and realized that we did not have the right staff to tdo the type During the implementation period of our CIA, we were faced with the challenge of effectively training 800 employees for 4 hours within 120 days across 350 miles! We developed an online training and tracking system to be sure that we reliably met this requirement. A formalized, consistent staff training program is one of the fundamental building blocks of a solid compliance program. The employee that is hired on Friday while the DON is on vacation needs to have the same training as the staff that are part of an official orientation program. This investment in training soon became a stand-alone online senior-care education business for me; Upstairs Solutions was launched as a separate entity in 2005. I like to say we made lemonade from lemons; our “home spun” online training program is now a nationally recognized training company. Upstairs Solutions now trains LTC staff throughout the US, from small single owner/operator locations to multi-chain multi-state organizations. Whether you choose to go with e-learning, traditional training or a blended learning approach, make sure the training is consistent, effective, trackable and addresses best practices. In addition, your training constantly needs to be re-evaluated to be sure it reflects the findings of the quality assurance committee Cheryl, CCO and myself sat down and carefully reviewed the training requirements and realized that we did not have the right staff to tdo the type During the implementation period of our CIA, we were faced with the challenge of effectively training 800 employees for 4 hours within 120 days across 350 miles! We developed an online training and tracking system to be sure that we reliably met this requirement. A formalized, consistent staff training program is one of the fundamental building blocks of a solid compliance program. The employee that is hired on Friday while the DON is on vacation needs to have the same training as the staff that are part of an official orientation program. This investment in training soon became a stand-alone online senior-care education business for me; Upstairs Solutions was launched as a separate entity in 2005. I like to say we made lemonade from lemons; our “home spun” online training program is now a nationally recognized training company. Upstairs Solutions now trains LTC staff throughout the US, from small single owner/operator locations to multi-chain multi-state organizations. Whether you choose to go with e-learning, traditional training or a blended learning approach, make sure the training is consistent, effective, trackable and addresses best practices. In addition, your training constantly needs to be re-evaluated to be sure it reflects the findings of the quality assurance committee

21. Meet Professor Maxwell! MEANINGFUL RELEVANT

23. Compliance as an Element of Employee Performance Adhere to compliance program Factor in performance Compliance is condition of employment Disciplinary action Compliance as an Element of Employee Performance. The program should require an employee to promote and adhere to the elements of the compliance program as a factor in evaluating the performance of all employees. Managers should be required to discuss with all supervised employees and contractors, as needed, the compliance policies and legal requirements related to their respective functions, inform personnel that strict compliance with the same is a condition of employment and warn them that the facility will take disciplinary action in the event of any violations. Compliance as an Element of Employee Performance. The program should require an employee to promote and adhere to the elements of the compliance program as a factor in evaluating the performance of all employees. Managers should be required to discuss with all supervised employees and contractors, as needed, the compliance policies and legal requirements related to their respective functions, inform personnel that strict compliance with the same is a condition of employment and warn them that the facility will take disciplinary action in the event of any violations.

24. Enforcing Standards and Disciplinary Guidelines Consequences Procedures for handling problems Disciplinary action Enforcing Standards through Well-Publicized Disciplinary Guidelines. Whether or not spanking is in your disciplinary repertoire at home, there must be some sort of consequences to enforce discipline. An effective compliance program should set out the consequences for employees or contractors who violate the facility’s standards of conduct, policies and procedures, and Federal and State laws. It should describe the procedures for handling such disciplinary problems. Intentional violations should result in significant sanctions, and negligent violations in some instances may also result in disciplinary action. Enforcing Standards through Well-Publicized Disciplinary Guidelines. Whether or not spanking is in your disciplinary repertoire at home, there must be some sort of consequences to enforce discipline. An effective compliance program should set out the consequences for employees or contractors who violate the facility’s standards of conduct, policies and procedures, and Federal and State laws. It should describe the procedures for handling such disciplinary problems. Intentional violations should result in significant sanctions, and negligent violations in some instances may also result in disciplinary action.

25. Internal Audit Systems and Quality Assurance Committee System to Identify Problems Correct Problems System to Evaluate QA&A Effectiveness Continuous Quality Improvement Annual Review Become Proactive Rather than Reactive Internal Audit Systems and Quality Assurance Committee : No facility or organization is perfect. We are people taking care of people. What is critical is that a system is in place to find your own problems, and when things are not perfect, that you have a plan to find the source of the problem, a plan for correcting it, and a plan monitoring that correction for effectiveness. I believe one of the most significant changes in our organization is the efficacy of our quality assurance program. Our staff now understands how to properly conduct a root cause analysis and make meaningful changes to our systems through continuous quality improvement. It is the role of the quality assurance committee to oversee clinical improvement and compliance issues throughout the organization. The findings of the Quality Assurance meeting are shard with the Board of Directors. We have evolved from a reactive organization to a proactive one. accountability for ensuring both quality of care and quality of life in nursing homes. The hallmark of CIA must have accountability no ostrich in the sand. Must be aware of what is going on in your facilities. The QAA meetings represent a key internal mechanism that allows a facility to deal with quality deficiencies in a confidential manner. The QAA is a management process that is ongoing, multi-level and facility wide not just nursing. Must find your own mistakes and correct systems that are broken and to find care processes that work. Encompasses all managerial, administrative, clinical and environmental service as well as the performance of outside , contracted providers and suppliers of services The QAA’s major purpose is continuous evaluation of facility systems with the objectives of: keeping systems functioning satisfactorily, preventing deviation from care processes, uncovering issues and concerns and correcting inappropriate care processes. Being able to spot and catch problems before they multiply is important in both a household and a facility. To demonstrate a compliance program’s effectiveness, the facility must thoroughly monitor its implementation of the compliance program through a process of ongoing evaluation, including regular, periodic compliance audits by internal or external evaluators with the necessary expertise in Federal and State requirements and private payor rules. Auditing should be designed to identify problem areas and resolve them. The facility also needs to review at least annually whether all the departments of the facility have satisfied each of the compliance program’s elements. Internal Audit Systems and Quality Assurance Committee : No facility or organization is perfect. We are people taking care of people. What is critical is that a system is in place to find your own problems, and when things are not perfect, that you have a plan to find the source of the problem, a plan for correcting it, and a plan monitoring that correction for effectiveness. I believe one of the most significant changes in our organization is the efficacy of our quality assurance program. Our staff now understands how to properly conduct a root cause analysis and make meaningful changes to our systems through continuous quality improvement. It is the role of the quality assurance committee to oversee clinical improvement and compliance issues throughout the organization. The findings of the Quality Assurance meeting are shard with the Board of Directors. We have evolved from a reactive organization to a proactive one. accountability for ensuring both quality of care and quality of life in nursing homes. The hallmark of CIA must have accountability no ostrich in the sand. Must be aware of what is going on in your facilities. The QAA meetings represent a key internal mechanism that allows a facility to deal with quality deficiencies in a confidential manner. The QAA is a management process that is ongoing, multi-level and facility wide not just nursing. Must find your own mistakes and correct systems that are broken and to find care processes that work. Encompasses all managerial, administrative, clinical and environmental service as well as the performance of outside , contracted providers and suppliers of services The QAA’s major purpose is continuous evaluation of facility systems with the objectives of: keeping systems functioning satisfactorily, preventing deviation from care processes, uncovering issues and concerns and correcting inappropriate care processes. Being able to spot and catch problems before they multiply is important in both a household and a facility. To demonstrate a compliance program’s effectiveness, the facility must thoroughly monitor its implementation of the compliance program through a process of ongoing evaluation, including regular, periodic compliance audits by internal or external evaluators with the necessary expertise in Federal and State requirements and private payor rules. Auditing should be designed to identify problem areas and resolve them. The facility also needs to review at least annually whether all the departments of the facility have satisfied each of the compliance program’s elements.

26. Root Cause Analysis “Every problem is an opportunity. Every defect is a treasure if the company can uncover its CAUSE and work to prevent it across the corporation.” Kilchiro Toyoda , founder of Toyota tool for identifying prevention strategies a process that is part of the effort to build a culture of safety and move beyond a culture of blame basic and contributing causes are discovered in a process similar to diagnosing a disease – with the goal of preventing recurrence. goal of root cause analysis examine WHAT happened ask WHY it happened determine WHAT to do to prevent it from happening again tool for identifying prevention strategies a process that is part of the effort to build a culture of safety and move beyond a culture of blame basic and contributing causes are discovered in a process similar to diagnosing a disease – with the goal of preventing recurrence. goal of root cause analysis examine WHAT happened ask WHY it happened determine WHAT to do to prevent it from happening again

27. Response to Problems & Developing Corrective Action Immediate investigation Steps to correct problem Plan of action Return overpayments Refer to authorities Responding to Detected Offenses and Developing Corrective Action Initiatives. A homeowner who ignores a leaking roof will end up with a much bigger and more expensive problem than if he had acted promptly. Similarly, if the compliance officer receives reports or reasonable indications of suspected noncompliance, there must be an immediate investigation to determine whether there has been a violation of law or other requirements and, if so, decisive steps to correct the problem. Corrective action may include developing a plan of action, returning overpayments, or referral to criminal or civil law authorities, among others. Responding to Detected Offenses and Developing Corrective Action Initiatives. A homeowner who ignores a leaking roof will end up with a much bigger and more expensive problem than if he had acted promptly. Similarly, if the compliance officer receives reports or reasonable indications of suspected noncompliance, there must be an immediate investigation to determine whether there has been a violation of law or other requirements and, if so, decisive steps to correct the problem. Corrective action may include developing a plan of action, returning overpayments, or referral to criminal or civil law authorities, among others.

28. Effectiveness of Compliance Program Evaluated periodically Address recurring problems Commitment of management Assessing Effectiveness of a Compliance Program. The compliance program must be evaluated periodically to assess its effectiveness as a whole, including how it performs in practice to monitor the facility’s operations on a day-to-day basis. If the same problems recur time and time again, something needs to be addressed. Comprehensive policies, standards and practices are only effective if they have the commitment of the facility’s management, are clearly written and communicated to staff, and are interpreted by a compliance officer with the requisite skills and experience. In the event of a regulatory investigation, thorough documentation of all aspects of the facility’s compliance program is necessary to demonstrate the facility’s good faith and the program’s effectiveness. Assessing Effectiveness of a Compliance Program. The compliance program must be evaluated periodically to assess its effectiveness as a whole, including how it performs in practice to monitor the facility’s operations on a day-to-day basis. If the same problems recur time and time again, something needs to be addressed. Comprehensive policies, standards and practices are only effective if they have the commitment of the facility’s management, are clearly written and communicated to staff, and are interpreted by a compliance officer with the requisite skills and experience. In the event of a regulatory investigation, thorough documentation of all aspects of the facility’s compliance program is necessary to demonstrate the facility’s good faith and the program’s effectiveness.

29. Review of Compliance and Nursing Policies and Code of Conduct Corporate Compliance Policies and Nursing Policies Relevant Reflects Best Practices Interdisciplinary Focus Understanding of Code of Conduct All Employees, Vendors, and Contractors Be sure your corporate compliance policies and nursing policies are relevant, reflect best practices and have an interdisciplinary focus. It is imperative[MPG1]  that your staff and vendors understand your organization’s code of conduct. Because nursing facility providers are subject to a large variety and number of laws, this part of a compliance program can be technical (for example, explaining the federal Anti-Kickback Statute), complex and lengthy.  So, the challenge for providers is how to translate these laws and policies into something that is manageable and understandable by employees at all levels.   To accomplish this, providers should develop Employee Standards and a Code of Conduct which is like a “Readers’ Digest” summary of the longer, more detailed summaries of law and policies contained in the compliance program.  This document is the primary tool which informs employees of the facility’s expectations regarding compliance issues.  The Employee Standards and Code of Conduct should summarize the basic principles and policies of the compliance program and teach employees how to raise questions about the law, company policy or program operation, as well as how to report workplace practices that may violate the law or company policy.  In most cases, this is the only document that will be routinely given to employees, although all employees should have access to the larger, more detailed written compliance program and be encouraged to review it.   The Employee Standards and Code of Conduct should be concise (some providers feel it should be no more than two to three pages long, but each provider has to decide what works best for their facility and employees), easily readable, and contain general principles.  It may also include examples of practices that may violate applicable law or policy to help illustrate potential problems.  In addition to the essential list of substantive “do’s and don’ts” for employees, it should also include the name or position of the individual employees should contact with compliance questions and to whom employees should report alleged or suspected violations of applicable law, company policy and/or the compliance program. It has become our organization’s policy that the code of conduct is reviewed and signed upon hire and then annually thereafter by all staff, vendors and physicians.  [MPG1]Why is this imperative? I think you need to elaborate. Policies and Procedures, Including a Statement of Corporate Philosophy and Codes of Conduct. Finally, the program should develop and distribute written compliance standards, procedures and practices to guide the facility and its employees on a day-to-day basis. These should include a code of conduct detailing the fundamental principles, values and framework for action within the organization; general corporate policies and procedures; a synthesis of key Federal and State laws and specific provisions for various clinical, financial and administrative functions within the facility. These should be easily understood by, and posted and distributed to, all affected employees, as well as physicians, suppliers, agents and contractors. Be sure your corporate compliance policies and nursing policies are relevant, reflect best practices and have an interdisciplinary focus. It is imperative[MPG1]  that your staff and vendors understand your organization’s code of conduct. Because nursing facility providers are subject to a large variety and number of laws, this part of a compliance program can be technical (for example, explaining the federal Anti-Kickback Statute), complex and lengthy.  So, the challenge for providers is how to translate these laws and policies into something that is manageable and understandable by employees at all levels.   To accomplish this, providers should develop Employee Standards and a Code of Conduct which is like a “Readers’ Digest” summary of the longer, more detailed summaries of law and policies contained in the compliance program.  This document is the primary tool which informs employees of the facility’s expectations regarding compliance issues.  The Employee Standards and Code of Conduct should summarize the basic principles and policies of the compliance program and teach employees how to raise questions about the law, company policy or program operation, as well as how to report workplace practices that may violate the law or company policy.  In most cases, this is the only document that will be routinely given to employees, although all employees should have access to the larger, more detailed written compliance program and be encouraged to review it.   The Employee Standards and Code of Conduct should be concise (some providers feel it should be no more than two to three pages long, but each provider has to decide what works best for their facility and employees), easily readable, and contain general principles.  It may also include examples of practices that may violate applicable law or policy to help illustrate potential problems.  In addition to the essential list of substantive “do’s and don’ts” for employees, it should also include the name or position of the individual employees should contact with compliance questions and to whom employees should report alleged or suspected violations of applicable law, company policy and/or the compliance program. It has become our organization’s policy that the code of conduct is reviewed and signed upon hire and then annually thereafter by all staff, vendors and physicians.  [MPG1]Why is this imperative? I think you need to elaborate. Policies and Procedures, Including a Statement of Corporate Philosophy and Codes of Conduct. Finally, the program should develop and distribute written compliance standards, procedures and practices to guide the facility and its employees on a day-to-day basis. These should include a code of conduct detailing the fundamental principles, values and framework for action within the organization; general corporate policies and procedures; a synthesis of key Federal and State laws and specific provisions for various clinical, financial and administrative functions within the facility. These should be easily understood by, and posted and distributed to, all affected employees, as well as physicians, suppliers, agents and contractors.

30. Exclusion Checks Not a criminal background check All employees, vendors and contractors BEFORE hire At least annually but OIG highly recommends monthly Check name on three sites: GSA:(General Service Administration) http://epls.arnet.gov  LEIE: (List of excluded individuals and entities) http://oig.hhs.gov/fraud/exclusions/exclusions_list.asp State OIG sites web site contains debarment actions taken by various Federal agencies, including exclusion actions taken by the OIG. For many years the Congress of the United States has worked diligently to protect the health and welfare of the nation's elderly and poor by implementing legislation to prevent certain individuals and businesses from participating in Federally-funded health care programs. The OIG, under this Congressional mandate, established a program to exclude individuals and entities affected by these various legal authorities, contained in sections 1128  and 1156  of the Social Security Act  , and maintains a list of all currently excluded parties called the List of Excluded Individuals/Entities. Bases for exclusion include convictions for program-related fraud and patient abuse, licensing board actions and default on Health Education Assistance Loans No payment will be made by any Federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. Federal health care programs include Medicare, Medicaid, and all other plans and programs that provide health benefits funded directly or indirectly by the United States No program payment will be made for anything that an excluded person furnishes, orders, or prescribes. This payment prohibition applies to the excluded person, anyone who employs or contracts with the excluded person, any hospital or other provider where the excluded person provides services, and anyone else. The exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person. Staff needs to understand the effects and significance of screening. Screening 4 days after hire and finding that someone was excluded can result in 4 days of payment to the facility that will have to be reported and returned to the government. A real area of focus for the OIG right now. The OIG updates the exclusion website at the end of the month so it is highly recommended to check monthly. Also you are responsible for checking DBA and name change. You don’t get brownie points for a cursory check. You are responsible for finding it. If you are receiving money from the government and you have an excluded person on staff it is considered overpayment and must be repaid promptly. The General Services Administration (GSA) maintains the list of parties that are debarred, suspended, or excluded from doing business with the government including exclusion actions taken by the OIG The LEIE contains just the exclusion actions taken by the OIG. web site contains debarment actions taken by various Federal agencies, including exclusion actions taken by the OIG. For many years the Congress of the United States has worked diligently to protect the health and welfare of the nation's elderly and poor by implementing legislation to prevent certain individuals and businesses from participating in Federally-funded health care programs. The OIG, under this Congressional mandate, established a program to exclude individuals and entities affected by these various legal authorities, contained in sections 1128  and 1156  of the Social Security Act  , and maintains a list of all currently excluded parties called the List of Excluded Individuals/Entities. Bases for exclusion include convictions for program-related fraud and patient abuse, licensing board actions and default on Health Education Assistance Loans No payment will be made by any Federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. Federal health care programs include Medicare, Medicaid, and all other plans and programs that provide health benefits funded directly or indirectly by the United States No program payment will be made for anything that an excluded person furnishes, orders, or prescribes. This payment prohibition applies to the excluded person, anyone who employs or contracts with the excluded person, any hospital or other provider where the excluded person provides services, and anyone else. The exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person. Staff needs to understand the effects and significance of screening. Screening 4 days after hire and finding that someone was excluded can result in 4 days of payment to the facility that will have to be reported and returned to the government. A real area of focus for the OIG right now. The OIG updates the exclusion website at the end of the month so it is highly recommended to check monthly. Also you are responsible for checking DBA and name change. You don’t get brownie points for a cursory check. You are responsible for finding it. If you are receiving money from the government and you have an excluded person on staff it is considered overpayment and must be repaid promptly. The General Services Administration (GSA) maintains the list of parties that are debarred, suspended, or excluded from doing business with the government including exclusion actions taken by the OIG The LEIE contains just the exclusion actions taken by the OIG.

31. Risk Areas Quality of Care Comprehensive Care Plans Medication Management Appropriate use of Psychotropic Medications Resident Safety Submission of Accurate claims Proper Reporting of Case Mix  Therapy Services Screening of excluded individuals and entities Restorative and Personal care services The OIG’s September 2008 Supplemental Compliance Guidance for Nursing Facilities includes “risk areas” upon which providers should focus in their corporate compliance programs The OIG’s September 2008 Supplemental Compliance Guidance for Nursing Facilities includes “risk areas” upon which providers should focus in their corporate compliance programs

32. Where We Are Today Are we proud of where we are today, yes….but friends let me tell you it was not a fun ride in the trenches on some days. Are we proud of where we are today, yes….but friends let me tell you it was not a fun ride in the trenches on some days.

33. Words of Wisdom Rome wasn’t built in one day! Make it a priority It’s all about the team Resources : AHCA www.ahcancal.org/facility_operations/ComplianceProgram/Pages/default.aspx AAHSA www.aahsa.org HCCA www.hcca-info.org If you don’t have a corporate compliance program or you are just starting out, it can feel very overwhelming. Chose one area to start and run with it. For instance, start incorporating exclusion checks into your hiring process. Take a good look at your training and make sure its meaningful and trackable. IF its not written and validated..its not done Don’t wait until 2013 to figure out compliance. When we got our CIA we were thrown into a very tight time ]line of implementing all the elements within 120 days. Sit with your team and set some realistic timelines. AHCA- American Health Care Association great series on getting a compliance program started in your organization including policies and procedures, webinars, HIPPA info AAHSA- American Association of Homes and services for the Aged Healthcare Compliance Association- Website has great links to oig and cms bulletins and whats happening in compliance. If you don’t have a corporate compliance program or you are just starting out, it can feel very overwhelming. Chose one area to start and run with it. For instance, start incorporating exclusion checks into your hiring process. Take a good look at your training and make sure its meaningful and trackable. IF its not written and validated..its not done Don’t wait until 2013 to figure out compliance. When we got our CIA we were thrown into a very tight time ]line of implementing all the elements within 120 days. Sit with your team and set some realistic timelines. AHCA- American Health Care Association great series on getting a compliance program started in your organization including policies and procedures, webinars, HIPPA info AAHSA- American Association of Homes and services for the Aged Healthcare Compliance Association- Website has great links to oig and cms bulletins and whats happening in compliance.

34. Words of Wisdom No right way or wrong way You can succeed Talk to providers I feel your pain! [email protected] 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 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

35. MY final thoughts Years of heartache-5 Dollars to the government- $4,000,000+ Hair Color to hide the gray-$1250 Botox-$3600 Corporate Compliance Plan without a CIA…..

36. PRICELESS

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