Tamar Abell (firstname.lastname@example.org) is a compliance consultant with 25 years’ experience in long-term care, based in Chicago.
Phase 3 of the Centers for Medicare & Medicaid Services (CMS) long-term care facilities Requirements of Participation (RoP) are a few months away from being enforced on November 28, 2019. Included in the requirements is “the operating organization for each facility must develop, implement, and maintain an effective compliance and ethics program.” The heart of any effective compliance program is the compliance committee. I have led and attended many compliance committee meetings over the years. These meetings have run the gamut from an occasion for donuts and coffee, to highly sophisticated analysis and discussions that would make the compliance gods smile. Whether you are just starting your journey in compliance or are a seasoned organization, here are some lessons I have learned in conducting effective compliance committee meetings, including the why, who, what, where, when, and how.
The very first question we need to ask is, why? Long-term care certainly has no lack of meetings and committees. The Health and Human Services Office of Inspector General (OIG) guidance for compliance in skilled nursing facilities (SNF) has been around since 2000 with supplemental information published in 2008, so why discuss it now?
One major reason―it is required by November 2019 in Phase 3 of the RoP for SNFs. The regulations do not specify that there must be a compliance committee, but it’s fair to argue that an effective program must have an effective compliance committee. The goal of this article is to make the most of the compliance committee, turning it from a regulatory “must” to a “want,” a mechanism to ensure compliance and a system of checks and balances.
Who within your organization should be part of the compliance committee? The OIG recommends “having the perspective of individuals with varying responsibilities in the organization such as operations, finance, audit, human resources and clinical management…all committee members should have the requisite seniority and comprehensive experience within their respective departments to implement any necessary changes.”
The corporate compliance officer chairs the committee and leads the meetings.
The committee is most effective with no more than 8–10 members; a larger committee becomes difficult to manage and less productive.
Many compliance issues are known at the lowest level of the organization. I learn so much about the culture and the issues when I include frontline staff. I recommend rotating frontline staff from different departments to the compliance meeting.
The members of the compliance committee should have a clear understanding of what their role is and verify that they want to be a member of the committee. I recommend preparing a “welcome packet” to committee members that includes the facility code of conduct, a review of the seven elements of a compliance program, and any additional links or articles about the role of the compliance committee in long-term care. I also provide them the charter for the compliance committee (more about that below).
In smaller organizations, owners often feel that at having a compliance committee is redundant. The ownership is often the same as the facility leadership, and much of the information is discussed daily in an informal mechanism. The compliance committee is a way to formalize what you discuss, perhaps daily, and give yourself credit for what you have self-assessed and corrected.