Quality managers should step up to the compliance plate to protect agency
You may be in the best position to galvanize compliance culture’
(Editor’s note: In a continuation of our compliance series, future installments will cover chapter by chapter how to create a home care compliance plan manual, and in another article, how to implement the plan and educate staff. Finally, assessing the plan’s effectiveness and periodically reviewing and updating your plan is essential, so Homecare Quality Management will provide upcoming articles with guidelines for these activities as well.)
The first step in creating a compliance plan for your agency is finding your compliance officer and granting that person the authority to get the job done.
While that may sound straightforward, the myriad ways different companies have approached this first step are as various as the species of fish in the sea.
Some home health companies have hired a person just to be the compliance officer, but others worry that if they did that, the person would not have enough to do on a day-to-day basis. Still other companies give the duty to their attorneys or to a chief financial officer.
But the experts agree on one maxim: Quality managers must be involved in compliance efforts. Whether you are actually the compliance officer or not, quality managers’ expertise is necessary for a corporate compliance plan to function effectively. And having a plan that doesn’t work may leave you more open to liability and penalty than not having one at all.
The reason is simple, according to Lawrence M. Leahy, MHA, CHE, CHCE, director of program integrity for Ruth Constant and Associates in Victoria, TX, which includes three full-service, freestanding Texas home health agencies. "Most compliance problems are in medical records," he says. "If you don’t have your quality improvement peoplewho are usually cliniciansto oversee medical records compliance, you’re not going to have an effective program."
As the compliance officer for his organization, Leahy was sure to include his director of clinical operations on the company’s compliance committee. While he says having a quality manager as the compliance officer is up to the individual company’s structure, a quality professional who has direct access to the agency’s board of directors would certainly be appropriate.
He cautions against one structure, however: having a compliance officer who handles day-to-day compliance issues and has no access to the board, but reports to a senior manager who does. This structure creates a barrier between the compliance officer and the board, because the senior manager may not want to raise an issue that might affect his or her job.
One of the seven Federal Sentencing Guidelines, on which all agencies’ compliance plans must be based, requires assigning a high-level person or group to oversee the plan. (See elements of the sentencing guidelines, p. 24.) This person must have access to senior leadership, which includes the board of directors, experts agree.
For example, Donna J. Escallier, RN, BSN, director of CQI and education for Partners Home Care (formerly the Five Hospital Homebound Elderly Program) in Chicago, not only has direct access to the board; she reports directly to the board in her role as compliance officer. And she has access to the legal advisor.
"That way I can bypass any of the vice presidents or the president if I feel I need to," she explains. "My reporting directly to the board makes the staff more comfortable, especially if there were ever to be something that involves a problem high up in the organization that the staff might be scared to talk about."
One reason the board and the senior leaders appointed her compliance officer is because as director of CQI, she is already responsible for compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, and state and federal regulations. Escallier oversees the seven people in the CQI department, which includes medical records.
Another reason is the way quality managers are perceived within the organization. "The QI department is like Switzerland," she says a staff member told her. "Nurses tend to view the CQI position as trustworthy," she explains. "They know we know the regulations and are unbiased."
Leahy agrees. "People might be more willing to confide in the QI person because they see them as a problem solver," he says.
Any compliance program begins with the support of your board of directors, who must adopt a compliance culture and tell management to get it done, says John E. Steiner, JD, associate general counsel for the American Hospital Association in Chicago. The quality manager has his or her work cut out after that, he tells Homecare Quality Management. "Your readers, the quality people, have to be empowered, authorized, and given this as a directive," Steiner says. Then they have a duty to start a process for identifying risk areas in their organizations.
Once the board of directors had issued its formal commitment to compliance, Leahy and his compliance committee then conducted an internal audit of operations. That meant a review of existing procedures and policies for identifying potential liabilities, and focusing on all the rules for Medicare and Medicaid programs, including the conditions of participation, reimbursement and cost-reporting rules, as well as anti-kickback and self-referral restrictions.
Such a review ideally will mirror your agency’s quality improvement program, which easily falls into the quality manager’s area of expertise, but also will include reimbursement rules and operational policies.
"Sit down and look at your operations manual," advises Ruth Constant, RN, BSN, MSN, EdD, president and CEO of Ruth Constant and Associates. "What’s in there that shows we comply with the conditions of participation? What are the policies that show we comply with JCAHO? What are the procedures to comply with labor laws, minimum wage, overtime, exempt and non-exempt employees? What about OSHA [Occupational Safety and Health Administration] Are you complying with their laws? Are your infection control standards current? What do you do about latex gloves and the red box used for syringes? That’s what a compliance program is all about. It’s not fancy words in some document. Do you comply with what you say you do in your everyday operations?"
Such a review will likely go a long way toward helping your agency set up the compliance plan, Constant says. "You will be overwhelmed at the information you have. You have an outline of compliance issues."
Steiner recommends doing a risk assessment that includes two phases: the reactive phase and the proactive phase. In the reactive phase, quality managers should assess their company’s risk in light of problem areas that current federal and state investigations have identified in home care, such as correctly determining homebound status, general and administrative costs on cost reports, and billing for visits that weren’t made. In the proactive phase, he recommends looking for the existence of internal controls to help prevent those operational problems and others. Assess whether your marketing people know the limitations that self-referral laws place on them. Note if you have procedures in place to track increases in volume and determine their cause.
"The essence of compliance is to identify risk areas, detect problems, take steps to fix the problem, and if you uncover any found money,’ give it back," says Steiner.
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