Designate a compliance officer. This individual is responsible for overseeing all compliance activities and ensuring the facility adheres to regulations. The compliance officer should have expertise in regulations applicable to long-term care facilities and coordinate compliance efforts across departments.
Conduct regular training. All staff must complete periodic training on key topics like resident rights, avoiding abuse and neglect, health and safety standards, and any recent changes to regulations. Trainings help ensure staff perform their jobs according to the latest requirements. They also help identify additional training needs. Training should be tracked so the facility can demonstrate accountability.
Review policies and procedures. The compliance officer should lead a comprehensive review of all facility policies, procedures, and protocols on a regular basis, at minimum annually. This helps identify any gaps or areas that need improvement to maintain compliance. Reviews also allow policies to be updated to reflect changes in laws, best practices, recent incidents, or other areas identified for strengthening.
Perform self-audits. In addition to external regulatory surveys, the compliance officer should develop compliance self-audit tools and schedules for internal audits. Audits help proactively identify potential problems before they are noticed by regulators. Areas that would be evaluated include things like infection control practices, resident care planning and services, staff training and qualifications, physical environment maintenance, and record-keeping accuracy. Audit findings should then be used to update policies, trainings, or other compliance activities.
Respond to complaints. The facility must maintain a process for receiving, investigating, tracking, and resolving all complaints from residents, family members, staff and others. Thorough responses help demonstrate that issues are taken seriously and addressed to prevent recurrences. They also allow regulators to see the facility is proactively identifying and working to remedy any compliance issues or quality concerns raised by complaints.
Maintain appropriate staffing levels. Facilities must adhere to minimum staffing requirements set by regulations, such as having a licensed nurse on duty at all times. They should also conduct periodic reviews to ensure staffing patterns align with actual resident acuity and care needs. Sufficient staffing helps minimize risk of things like neglect due to high workloads. It also reduces risk of regulatory deficiencies for understaffing.
Collect and analyze key metrics. The facility should track compliance-related metrics over time, including things like numbers/types of staff trainings completed, audit findings and corrections, the frequency and severity of all complaints received and how they were addressed, the occurrence of any resident injuries or other adverse events, and outcomes of regulatory surveys such as citations received. Analyzing this data identifies trends that may warrant further attention or quality improvements to reduce compliance risk in the future.
Respond promptly to survey deficiency notices. Receiving citation of regulatory non-compliance or deficiencies is inevitable at some point for any long-term care facility. It is important to provide detailed, timely responses and corrective action plans that fully address each cited deficiency and underlying compliance issues. Regulators will evaluate whether the facility recognizes problems and is committed and able to correct them to achieve durable compliance. Prompt, comprehensive responses can help minimize subsequent enforcement actions.
Partner with external consultants. Contracting with compliance or elder care law consultants helps the facility stay up-to-date on any changing regulatory requirements through expert guidance, reviews, gap analyses, trainings and templates. Consultants also provide another level of quality oversight and review that is independent of normal facility operations. This can reassure residents, families and payers that compliance receives diligent focus. Consultants’ input can strengthen the facility’s compliance efforts over time.
Maintaining a strong culture of ongoing compliance oversight, accountability, continuous improvement and proactively addressing any issues identified are key strategies for a long-term care facility to help sustain adherence to all applicable regulations over time. A comprehensive, multi-faceted compliance program is necessary to address this important responsibility for the well-being and safety of residents entrusted in the facility’s care.