Healthcare Compliance Presentation
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Health Care Compliance requirements...coming to a neighborhood near you~!

Health Care Compliance requirements...coming to a neighborhood near you~!

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  • 1. CINNTI – “confirmation of workplace protection for everyone”Presenter: Kendall Brune, PhD, MBA, LNHAFellow – American College of Healthcare AdministratorsCompliance and BeyondIt does not matter how smallor LARGE your complex is12 room ILF- VA276 bed SNFIt is a Scary Proposition~!
  • 2. Compliance is a LEAP of FAITH
  • 3. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare companies have seen the development of mandatory compliancerequirements increase over the past few years. The sources of theserequirements include:• US Sentencing Guidelines• OIG/Health and Human Services Guidance• Medicare Part C & D Mandatory Compliance Guidelines• Affordable Care Act• FAR Acquisition Regulations.
  • 4. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondRecently, mandatory compliance requirements were enacted through statute inthe Affordable Care Act (Sections 6102 and 6401). Under the ACA, companies areprohibited from participating in Federal heath care programs unless theircompliance programs contain certain core elements.The ACA sets out required core elements. The HHS regulations are likely to drawfrom the statute and from earlier regulatory proceedings which solicited input onthe basic compliance program requirements.Nursing homes will be expected to have operational compliance programs thatare effective in preventing criminal and civil health care violations, andpromoting quality of care by March 23, 2013.What does this NH regulation have to do with my ALF?
  • 5. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceWhat is a ―sanctioned entity ?Entity convicted of any criminal offense that triggers a mandatory exclusionunder Section 1128(a), including:• Felony conviction for health care fraud;• Conviction related to patient abuse and/or neglect;• Failure to repay Health Education Assistance Loans;• Conviction related to fraud against non‐health care programs;• Misdemeanor conviction for controlled substances;• License revocation or suspension; and• Misdemeanor health care fraud conviction.Share FBI and OIG cards –Welcome to my ALF~!
  • 6. Fact SheetALF and Wrongful Deaths?Public defender Kathryn Benson, left,talks with Richard Allen Williamsfollowing his arraignment in BooneCounty (Mo.) Circuit Court. Williams, 36,pleaded innocent Monday to 10 counts offirst-degree murder for allegedly killingpatients a decade ago while working as anurse at the Truman Memorial VeteransHospital in Columbia, Mo. Boone CountyProsecutor Kevin Crane told the court hewould seek the death penalty in the case.(July 23, 2002)An investigation by the FBI and the Office of Inspector General in theDepartment of Veterans Affairs determined that 41 people died on Ward 4Ebetween May and August 1992 while Williams was on duty. Investigatorsconcluded patients were 20 times more likely to die while Williams was workingthan while 11 other nurses were on duty.
  • 7. Owners did not check out his Background? His license was not suspended…. The VA did not report any problems…. The Administrator was glad an RN applied…. Meanwhile, the number of deaths increased at Ashland during thetime Williams was there. From June 1993 to June 1994, more thanhalf the homes 55 residents died - nearly triple the average deathrate for nursing homes in Missouri. The Boone County medicalexaminers office focused on 30 deaths that occurred during theyear Williams worked at Ashland. Six residents died in the 10 months after Williams dismissal fromthe home on July 13, 1994. No charges resulted. Williams wasremoved after state inspectors found that he had failed toadequately supervise staff to ensure the safety, treatment and careof residents. http://murderpedia.org/male.W/w/williams-richard-allen.htm
  • 8. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceAffordable Care Act (ACA) core requirements should include:1. Written policies, procedures and standards of conduct to prevent and detect inappropriate behavior.2. Designation of a chief compliance officer.3. Effective education and training programs for the governing body for all employees.4. Maintenance of a hotline and anonymous reporting procedures to protect the anonymity ofcomplainants and to protect whistleblowers from retaliation.5. A system to respond to allegations of improper conduct and the enforcement of appropriatedisciplinary action against employees who have violated internal compliance policies, applicablestatutes, regulations or Federal health care program requirements.6. The use of audits and/or other evaluation techniques to monitor and track compliance andassist in the reduction of identified problem areas.7. The investigation and remediation of identified systemic problems including making any necessarymodifications to the organization’s compliance and ethics program.
  • 9. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceWhat are you doing about your compliance and how comfortable areyou that your current licensed staff / vendors?• Are properly licensed• Have no Sanctions or Disciplinary Actions• Maintain required Certificates• Are not Excluded or Debarred by OIG/GSA• Maintain proper Continuing Education• Files are ready for Joint Commission or State auditsRooting out health care fraud is central tothe well-being of both our citizens and theoverall economy. http://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud
  • 10. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceRecommended program levels for current licensed staff and vendors:Compliance Plans Minimum Medium MaximumGeneral Services Administration Excluded Parties List System (GSA) X X XOffice of the Inspector General List of Excluded Individuals/Entities (OIG) X X XOffice of Foreign Assets Control Specially Designated Nationals (OFAC) X X XState exclusions, sanctions, and debarment X X XInstant SSN (social security number) Trace X X XNational Practitioner Data Bank (NPDB) X XProfessional License Verification X XNationwide Federal Criminal Record Search X XStatewide Criminal Records Search X XRegistered Sex Offender Search X XEthics Training XContinuing Education Training X
  • 11. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceLicensed Employees Only?Do you have one place to go to determine the compliance for your entireorganization?2012, American Senior Communities recently settled with the OIG for $376,000for employing 7 excluded providers. Fines included CNAs and kitchen staff.Housekeepers?Drivers?Transporters?Dietary Staff – OH YesVOLUNTEERS?My Dietary Manager
  • 12. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceRecommended program levels for non-licensed staff and vendors:Compliance Plans Minimum Medium MaximumInstant SSN (social security number) Trace X X XNationwide Federal Criminal Record Search X X XStatewide Criminal Records Search X X XRegistered Sex Offender Search X X XEthics Training X X XEmployment & I9 Verification X XW-9 Verification X XWorkers Compensation Insurance Verification X XGeneral Liability Insurance Verification X XBusiness Partner / Owner Search X XCounty Civil / Lawsuit Search X
  • 13. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceThe cost of not knowing?Medicare/Medicaid Billing Participation1. Up to $10,000 fine for each item/service billed2. Treble (3x) damages3. Possible exclusion4. Charges under Federal False Claims ActLegal Liability1. Negligent hire or retention2. Loss of CMS Reimbursement Privileges (PPACA 6502)3. State fines for practicing without a license Has it effected you, it has me~! RN & LPN story
  • 14. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceThe cost of not knowing? – 2 examplesExample #1 - The U.S. Justice Department has accused RehabCare Group Inc. of paying more than $10million in kickbacks to gain access to Medicare and Medicaid patients in Missouri nursing homes.RehabCare began making payments in 2006 to induce a Missouri nursing home chain to grantRehabCare a contract to provide therapy services.RehabCare’s revenue-sharing arrangement with the nursing home owner -- Sikeston, Mo.-based HealthSystems Inc. -- defrauded the federal Medicare and Medicaid programs of millions of dollars, federalinvestigators allege.Example # 2 - California’s Attorney General announced that the former director of nursing at a hospitalin the Kern Valley Healthcare District was sentenced to three years in state prison for the “conveniencedrugging” of elderly patients, including one who ended up dying.Gwen D. Hughes, the former nursing director, was charged with the deaths of three patients in theoriginal lawsuit. She pled no contest to a single felony count of elder abuse last October, with a specialallegation that the abuse resulted in the death of a patient.
  • 15. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceThe cost of not knowing?OIG also excluded 3,131individuals and entities fromparticipation in Federal healthcare programs in FY 2012. OIGreported 778 criminal actionsagainst individuals or entitiesthat engaged in crimes againstHHS programs; and 367 civilactions.The OIG reported $6.9 billionin expected recoveries whichconsisted of $923.8 million inaudit receivables and $6 billionin investigative receivables for FY2012.Date Provider Self-Disclosure?Amount of CMPAssessed11/13/12 Hospital Yes $248,362.7810/12/12 Hospital & CardiologyPracticeYes $172,604.0010/12/12 Physician d/b/a Physician’sMedical ClinicYes $43,014.8010/07/12 Home Health Agency Yes $81,102.0610/07/12 Hospital Yes $150,000.0009/26/12 Hospital Yes $120,580.2509/25/12 Treatment Center Yes $105,794.2409/19/12 Neighborhood Health Clinic Yes $103,485.7909/19/12 Hospital Yes $417,440.7808/22/12 Hospital Yes $138,452.0008/02/12 Hospital Yes $206,669.5307/13/12 Community Clinic Yes $207,440.19Sample listing
  • 16. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceGCT Advantages• More than just a background check• Each compliance package is customized• Employee and vendor screening• No Cost for certifying outside vendors• International capabilities• Our system monitors monthly for changes• Nationwide databases• Secure documentation management• State of the art security to protect all data• On-site user interface for security or visitor centerGCT is a simple, efficient, cost-effective solution to manage your compliance withconfidence. We also recognize that your operations must always remain audit ready.Why? We’ve been there as licensed Administrators~!...been there with Federal Surveyors,with FBI and OIG. It is NOT pretty or a cake walk.
  • 17. CINNTI – “confirmation of workplace protection for everyone”Compliance and BeyondHealthcare and Long Term Care ComplianceFor any questions contact:GCT – Healthcare and Long Term Care Compliance ExpertKendall Brune PhD, MBA, LHNA, FACHCAKendall.brune@kaegem.comPhone: 314-757-0131Global Compliance Trackera KAEGEM division2800 West Higgins Road, Suite 980Hoffman Estates, Illinois 60169Toll Free:1-888-327-6067E-mail: info@gct-cinnti.com