We’re breaking down the Requirements of Participation Phase 2 updates and Phase 3 new guidance.
Today we’re focusing on F895-Compliance and Ethics.
Look for additional updates each week through October.
§483.85-Compliance and Ethics
What’s new: Survey enforcement for the standards for nursing facilities to have a compliance and ethics (C&E) program will begin on October 24, 2022.
What you need to know:
CMS regulations include eight required components of a C&E program, three additional components for organizations operating five or more facilities, and a required annual review.
Surveyors will be reviewing the written policies and procedures and interviewing both staff and high-level personnel overseeing the program to determine if this program is in place.
They will look for examples of the compliance program in action, evidence of the annual review, and that the organization has completed due diligence on the high level personnel overseeing the program.
Action for facilities:
Use AHCA’s Action Brief to review existing C&E program to ensure it meets the requirements for all components.
Use the facility assessment to evaluate the needs of the C&E programs, including identifying risk areas, developing and maintaining the program, and determining resources.
Integrate the C&E program with the QAPI program required in 483.75(g)(2)(iii). This includes integrating the information and data collected and having the QAPI officer work with the compliance officer to determine if there are trends or patterns of systematic problems.
Deliver and track annual training to staff, vendors, and contractors in accordance with C&E training requirements in 483.95(f).
Ensure staff has familiarity with the C&E program and can answer questions asked by surveyors.
