How do you know if you NEED a Compliance Gap Analysis when you might not even know what a compliance gap analysis is?

A compliance gap analysis is a detailed review of your company’s compliance health. It reviews your plans and controls within the organization to see if they are maintaining the state of compliance that you desire. To put it simply, if you start with an outline of your current state of compliance, then review the desired state, based on regulations, and find that there are gaps, that is the Compliance Gap Analysis. An action plan to mitigate the gap is the next required step.

The benefits of completing a Compliance Gap Analysis, before you have something happen externally that brings the gap to your attention include:

  • It helps you prioritize your compliance efforts
  • It allows you to enable proactive risk mitigation
  • It will save you money in the long run
  • It will add structure and formality to your compliance plan and processes

If you operate a Skilled Nursing Facility (SNF), you might know that one of the requirements is to have a Compliance Plan. OIG SNF guidelines for compliance published in the Federal Register discuss the expectation to have a Compliance Plan in place in 1999. On March 16, 2000, the Department of Health and Human Services, Office of the Inspector General also know as OIG, released Compliance Program Guidance for Nursing Facilities to promote “a higher level of ethical and lawful conduct throughout the entire health care industry”. The OIG guidance recommended seven elements which should be included in an effective, comprehensive compliance and ethics program:

  1. Implementing written policies, procedures and standards of conduct
  2. Designation of a compliance officer and compliance committee
  3. Conducting effective training and education
  4. Developing effective lines of communication
  5. Enforcing standards through well‐publicized disciplinary guidelines
  6. Conducting internal monitoring and auditing
  7. Responding promptly to detected violations and corrective action

The new F‐tag F895 for the Compliance and Ethics Program was revisited in October 2023. The purpose of the refreshed surveyor focus on compliance is to ensure that facilities have in operation an effective compliance and ethics program that uses internal controls to more efficiently monitor adherence to applicable statutes, regulations and program requirements to deter criminal, civil and administrative violations and promote quality of care for nursing home residents. The CMS Presentation on Compliance and Ethics Requirements outlines specific expectations that the surveyors will be reviewing if you operate 1-4 SNFs or if you have over 5 SNFs.

If you are reading this blog and realize that you do not have all of your compliance plan requirements in place, you are a good candidate for a Compliance Gap Analysis. Identification of your gaps will allow you to minimize risk and begin the steps to being in compliance.

If you have questions, wish to discuss where to start, or to have a Gap Analysis, contact Kay Hashagen, PT, MBA, RAC-CT at [email protected] or (410) 777-5999.