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Anatomy of a Compliance Plan…One Size Does Not Fit All!


EDITOR’S NOTE:  Kathleen Hessler, RN, JD, presented “Hone in on Home Health and Hospice Compliance and Quality: The Government Is Watching” at the American Health Lawyers Association’s Long Term Care & the Law Conference, Las Vegas, Feb 19-21, 2014.  She is based in Albuquerque, NM. 

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Timing has always been key in admitting a patient for home health or hospice care. In an ideal scenario, health professionals focus on timely arrangements to effectively carry out an appropriate plan of care that supports the patient’s goals, diagnosis, and wishes in familiar surroundings that support optimal health and well-being. 

According to Kathleen Hessler, RN, JD, Director of Compliance & Risk at Simione Healthcare Consultants, timing is also critical for our nation’s home care and hospice providers to ensure they effectively navigate the compliance and risk requirements dotting the healthcare landscape with increasing frequency each year. 

“Home care and hospice organizations of every size and scope must learn to continuously assess and manage their risk as the government works increasingly harder to validate the millions of dollars spent on home health and hospice services every year,” says Hessler, a former critical care nurse and legal expert who focuses on helping post-acute providers assess, create and manage effective compliance and risk programs.  “Even though this is still unfamiliar territory to many post-acute providers, the government has already confirmed many reports of fraud, abuse and waste in home care and hospice practices, resulting in settlements large enough to close many organizations, regardless of size.”

The Patient Protection and Affordable Care Act, also known simply as the Affordable Care Act, of 2010, requires that all Medicare-certified providers establish and implement an Ethics and Compliance Program that contains core elements established by the Department of Health and Human Services and Centers for Medicare and Medicaid Services (CMS).

When it comes to having the right compliance program for your organization, Hessler cautions that “one size does not fit all.  In fact, if your program fits, try it on again!  A truly effective compliance plan is one that is always in action, evolving and changing to meet the needs of your organization in light of new requirements.”

Based on many industry resources and her experience in helping post-acute providers assess their risk, Hessler outlines the seven core elements of an effective compliance plan:

  • Written policies and procedures to include high risk areas of practice, and written company standards/code of conduct
  • Oversight by an organizational compliance officer, governing body and compliance committee
  • Development and implementation of regular, applicable education and training for all employees
  • A reporting system (such as a hotline) to receive complaints and ensure effective communication between the compliance officer and employees (with option for anonymity)
  • Use of audits and other systemic practices to monitor compliance, identify problem areas, and implement correct action
  • Established disciplinary measures to enforce standards of conduct, address violations, and apply applicable sanctions
  • Policies that ensure prompt investigations, reporting and corrective action for compliance issues

“If you don’t have a comprehensive compliance program, do not despair.  A systematic, and then annual review of your organization’s compliance practices will help minimize risk and support both clinical and financial success,” Hessler says.  “First, identify the compliance measures you already have in place through your policies for clinical operations, billing and claims submissions, quality/performance improvement, electronic medical records, and human resources.”

With this inventory completed, Hessler suggests that home care and hospice organizations then identify high-risk compliance concerns as detailed in CMS resources, Corporate Integrity agreements (CIA), and the Office of Inspector General (OIG) work plans.

“Specifically for hospice, CMS changes in 2013 and 2014 will dramatically change reporting eligibility, documentation, and scope of coverage.  Home health and hospice organizations should explore the government online tool kits and develop a check list of key issues.  A systematic approach will guide these organizations to refine their operations in a climate where oversight is ongoing and pervasive,” Hessler explains.  “A continuous commitment to assess, audit, measure and monitor compliance will facilitate high-performance home health and hospice operations – both clinically and financially – to ensure these organizations are able to continue their vital work on behalf of the patients and communities they serve.”