Develop your own compliance plan

Agencies can audit processes, take corrective action

Compliance planning doesn’t have to be a drawn out, expensive process involving lawyers and consultants, says Ruth Constant, RN, MSN, EdD, CHCE, president of Ruth Constant & Associates of Victoria, TX.

Constant, whose company owns and operates three Texas home health agencies, says that a smaller agency not only can develop its own compliance plan, but should follow through with an ongoing process of implementation, review, and improvement to make it a real compliance program.

"You don’t write a plan, put it in a manual, and stick it on a shelf. That is not a compliance program," she says. "I see the corporate compliance plan as your blueprint, your schematic. Your plan is your pattern to develop a corporate compliance program, which is a dynamic, ongoing process."

Creating that plan requires an agency taking a long, hard look at itself — how well it follows its own policies and how well those policies mirror existing law. Sometimes making such a detailed self assessment can be a little daunting to an agency.

"Some people say, No, we run a good organization; we don’t have problems,’" Constant says. "They’re in the position that they don’t know that they have problems. But I would rather find out myself than let the surveyor come in and tell me, You’re committing fraud.’ Or, This is so bad we’re going to take your license away,’ or You’re deficient in your survey.’"

Self audit

The agency’s self-examination can take the form of an initial internal audit — a substitute for the expensive legal audit that a lawyer might do of the agency.

Constant suggests creating a large checklist breaking down the major components of the organization — generally clinical, operational, and financial — and checking them against all relevant regulations, including Medicare conditions of participation, Occupational Safety and Health Administration requirements, and state licensing rules.

In each case, she suggests asking two questions:

1. Do our policies address what the law requires?

2. Are we actually following our policies?

"The simplest way that I can suggest is to get your manual and look at it," she advises. "It’s probably in sections — clinical sections, where you give care, administrative operational, and financial. All tie together, but they are separate little entities that have their own tasks and responsibilities."

In the billing section, for example, an agency would look at its billing processes, examining policies, and procedures. Is the agency waiting to bill for Medicare services until it has obtained a signed physician’s order?

Another example would be to check to see whether nurses are asking patients about advance directives upon admission into home care.

"Are all your policies up to date?" Constant asks. "How long has it been since they were revised?"

Throughout the audit, the agency should be identifying areas of weakness and documenting them thoroughly. Although it would clearly be illegal to go back and change past documentation, an agency can show regulatory agencies that it identified a problem and corrected it.

"Ninety-nine and nine-tenths percent of home health agencies are basically honest and want to do a good job," she says. "They may hire new people who somehow didn’t remember when they were told not to bill until they had a signed doctor’s order for those visits that the nurses made during the month."

Obtaining signed orders is a frequent problem Constant encounters when discussing other agencies’ operations. Operators recognize that they need to have the orders before billing Medicare, but have trouble tracking down busy physicians in order to obtain them.

Corrective action — and beyond

Once problem areas have been identified, the plan must be developed to address them. Policies must be updated as needed, and necessary inservicing must be conducted to reinforce regulations that employees haven’t been following.

Constant suggests creating a compliance team that includes the top managers from each department, and in a far-flung agency, from each office. Her agency has a corporate compliance officer, originally hired as director of program integrity. He heads the compliance council, is responsible for coordinating its activities, and handles complaints regarding compliance issues.

While some may suggest keeping an attorney on contingency to serve as compliance office, Constant says there are disadvantages to that approach. "Lawyers don’t know all about how home health agencies operate. Even those who specialize in home health care really don’t know as much as people who actually work in the organization."

She says it is important that a compliance officer be someone who is respected by peers as fair and principled, and he or she be given enough autonomy to do the job without interference. Ultimately, however, autonomy must go hand-in-hand with a top-down commitment to compliance by the entire organization.

"Compliance has to start at the top, certainly in family-held or privately held home health agencies," Constant says, noting that in her organization, she is not only the administrator, but the owner and president of the board of directors. "If I were dishonest, who would the compliance officer go to?"

The commitment to behaving ethically is disseminated throughout the company as a regular part of training. In Constant’s agencies, not only are employees required to have continuing compliance education, but board members must also go back to the classroom yearly.

Employees are taught that falsifying documentation is a firing offense. "They know we don’t falsify records, even a blood pressure," Constant says. "If a person makes a mistake, they may be counseled. But you don’t go back and change records because you think you’re going to be in trouble."

And every aspect of compliance — the audit, the education, implementation of the program — is copiously documented. At the mandatory compliance inservice, employees must sign in to show that they attended. The compliance officer keeps confidential records of any complaints, along with documentation of with their disposition.

Once a plan has been developed and implemented, the compliance program has just begun. In fact, Constant says, a good compliance plan should have built in mechanisms for review and updating, ideally every year.

The compliance officer keeps track of new regulations from state and federal agencies, making note of those that can wait till the yearly revision and immediately implementing important changes to documentation or procedures.

"You cannot write a policy today and two years from now, that policy remains the same," she says. "They’re always being revised, even if it’s just improving the way it is written."

She says that with every policy at her agencies, the manual notes when it was written, and when it was reviewed or revised. As with every other aspect of operations, agencies must be sure to follow their own requirements regarding policy review.

"If you say in a policy that you’re going to review policies every year, then you document that you did it. You don’t have to change a word, but at least you reviewed it."

Ruth Constant, Ruth Constant & Associates, 1501 E. Mockingbird Lane, Suite 404, Victoria, TX 77904. Telephone: (561) 578-0762. Fax: (561) 578-1567. E-mail: Web site: