Facility: A 120-bed Skilled Nursing Facility (SNF) located in a suburban area.

Essential Elements:

• Leadership Commitment: Secure written commitment from the administrator and board of directors demonstrating their support for the compliance program.
• Compliance Officer: Designate a qualified individual (e.g., RN, compliance professional) to oversee the program implementation and day-to-day operations.
• Risk Assessment: Conduct a comprehensive risk assessment to identify areas of potential non-compliance with relevant regulations (e.g., Medicare, state licensing).
• Policies and Procedures: Develop and implement written policies and procedures that address identified risks and comply with regulations.
• Training and Education: Train all staff (clinical, administrative, support) on relevant policies and procedures, regulations, and compliance best practices.
• Communication: Establish clear communication channels to foster open reporting of compliance concerns and suspected violations.
• Monitoring and Auditing: Conduct regular monitoring and audits to identify and address potential compliance issues.
• Corrective Action: Implement a system for investigating and addressing identified compliance issues, including disciplinary action if necessary.
• Recordkeeping: Maintain comprehensive records of all compliance activities, training, monitoring results, and corrective actions.

Implementation Team:

• Compliance Officer: 1 full-time position.
• Compliance Committee: Comprised of representatives from various departments (e.g., nursing, therapy, administration) to meet quarterly.
• Trainers: Utilize internal staff with expertise in specific areas or hire external trainers for specialized topics.

Training:

• Conduct initial training for all staff within 3 months of program launch.
• Provide ongoing training at least annually, addressing updates to regulations, policies, and identified areas of need.
• Utilize diverse training methods (e.g., in-person sessions, online modules, job-shadowing) to cater to different learning styles.

Policies and Procedures:

• Key required policies: Code of Conduct, Anti-Discrimination, Resident Rights, Infection Control, Medication Management, Emergency Preparedness, Data Privacy.
• Develop additional policies based on identified risks (e.g., Billing and Coding, Conflict of Interest, Gift Acceptance).

Data Collection and Monitoring:

1. Incident Reporting System: Implement a user-friendly system for staff to report suspected violations or compliance concerns anonymously.
2. Internal Audits: Conduct regular audits of key areas like medication administration, documentation, and care practices.
3. External Reviews: Partner with external auditors to perform periodic comprehensive reviews of the compliance program.

Addressing Failure:

• Investigate all reported concerns and suspected violations thoroughly.
• Implement corrective actions proportional to the severity of the issue, including retraining, disciplinary action, or termination.
• Track and trend identified issues to inform program improvement efforts.

Evaluation:

• Conduct annual program evaluations to assess its effectiveness in achieving compliance goals and preventing violations.
• Utilize data from monitoring, audits, and incident reports to inform the evaluation.
• Share evaluation results with leadership and staff, and make necessary adjustments to the program based on findings.

Additional Considerations:

• Tailor the program to the specific needs and risks of the SNF.
• Seek input from stakeholders (staff, residents, families) throughout the implementation process.
• Maintain ethical compliance practices throughout the program, ensuring confidentiality and protecting individual rights.

Disclaimer: This plan serves as a template and should be adapted based on specific regulations, facility size, and organizational structure.