SNF Compliance & Ethics Toolkit

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SNF Compliance & Ethics Toolkit

Product Code: SNFCTLKT

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Available May 2018

SNF Compliance & Ethics Toolkit

Stefanie Corbett, DHA
Nancy Beckley, MS, MBA, CHC

Available May 2018

Compliance and ethics are not performance measures; they are a philosophy

According to the 2016 revisions to the Conditions of Participation, CMS mandates that facilities implement a compliance and ethics program by November 28, 2019, something that has not been surveyed before.

This updated version of the SNF Compliance & Ethics Toolkitincludes new sample policies and even more downloadable resources to help your facility be ever-vigilant for high-risk, problem-prone areas; identify key areas of noncompliance based on previous Office of Inspector General reports; and monitor claims for accuracy to avoid financial and marketing hardships.

This resource offers practical, efficient ways to train and educate staff, develop self-correcting actions, and stay on top of the constantly changing regulatory environment in long-term care.

This book will help providers:

  • Save time developing compliance & ethics policies and procedures by using the new and updated downloadable samples, which can be customized and implemented immediately
  • Perform efficient and effective facility assessments, implement quality improvement strategies, and ensure resident-centered care with access to more than 40 downloadable forms and tools carefully created by industry veterans
  • Create a training program that ensures veteran and new staff alike are being educated appropriately to maintain compliance
  • Develop a process to identify and address high-target areas that may raise red flags for an auditor
  • Avoid deficiencies by learning how to perform corrective actions to address potential risk areas identified during an internal audit
  • Establish clear interdisciplinary lines of communication and develop a plan to enforce accountability

Page count: 200
Dimensions: 8.5 x 11
ISBN: 978-1-68308-708-3

Table of Contents



Section I: Written Policies and Procedures
Corporate Compliance Program
Code of Conduct for SNF
Corporate Compliance Department Charter
Acknowledgement of Compliance
Corporate Compliance Posttest
Posttest Answer Key

Section II: Compliance Officers and Committees
Compliance Committee Charter
Director Audit and Compliance Job Description
Compliance Specialist Job Description
General Job Description Template
General Performance Review Template
New Manager Knowledge & Skills Assessment

Section III: Allocate Sufficient Resources and Authority

Section IV: Exercise Due Care to Avoid Delegation of Substantial Authority
Employee and Vendor Exclusion Screening—LEIE/OIG
Sample Policy on Exclusion Screening
Employee License Verification
Sample Policy on License Verification

Section V: Conducting Training and Education
Compliance Training Program Outline
Compliance Training Program Outline Therapy Services
Coding Compliance
Employee Compliance Training Record
Attendance Sheet

Section VI: Auditing and Monitoring
Compliance Auditing Tool
MDS Chart Audit Tool
CAA Completion Audit Tool
Quarterly Compliance Visit Report
Part A Triple Check
Part B Triple Check
Assessment Itinerary Announced Site Visit
Checklist for Unannounced Audit
CMS Resident Review Worksheet
Quality of Life Resident Interview
Quality of Life Family Interview
Quality of Life Group Interview
State Survey Form

Section VII: Enforcing Standards and Disciplinary Guidelines
Disciplinary Notice

Section VIII: Responding to Detected Offenses (Response and Prevention)
Grievance Policy and Procedure
Assistance Form
Compliance Bulletin Board Posting
Hotline Poster
Poster on Suggestion Box
Intercommittee Action Request
Meeting Checklist
Meeting Attendance Record
Meeting Minutes
Medicare Meeting Minutes Format
Medicare Meeting Log Part B

Section IX: Risk Assessment
The OIG’s Role
Questionable Billing by SNFs
OIG Report White Paper