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Compliance investigation and reporting in skilled nursing facilities

April Bernabe (april.bernabe@healthstream.com) is Long-term Care Quality Analyst/abaqis Operations Manager at HealthStream Inc. in Denver, CO.

The nursing home industry is subject to numerous federal and state statutes, rules, and regulations, and skilled nursing facilities (SNFs) are required to investigate and report occurrences and events that meet defined criteria. Federal and state criminal and civil enforcement actions related to substandard quality of care can also lead to various governmental investigations. SNFs that have an established compliance and ethics program that includes robust investigation and reporting are in a better position of meeting fiduciary duties to provide quality care while navigating the challenges of evolving regulatory and enforcement actions.

SNFs are accustomed to conducting investigations, but most of these investigations are related to different clinical, financial, and administrative functions, or in relation to self-disclosed reports to federal and state agencies. Most of these investigations are handled by the SNF’s management team; occasionally, human resources management and/or legal counsel become involved when the subject of the investigation is beyond the purview of the nursing home administration. In contrast, compliance investigation and reporting are relatively new and require more structuring in terms of policies and procedures, tools, and training.

Compliance investigation may be defined as an internal investigation, “often conducted by compliance officers, internal audit departments, [and/or] outside counsel,” and designed to conduct “factual review and legal analysis of potential problems,” significant wrongdoing, misconduct, or ethical lapses.[1] In SNFs, these investigations may result from reports of wrongdoing from the compliance hotline learning of whistleblower complaints, information that the insurance carrier or fiscal intermediary is conducting an audit, or notification from a governmental agency in a form of request for documents, subpoena, or search warrant.

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