The Long-Term Care Compliance Toolkit

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The Long-Term Care Compliance Toolkit

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The Long-Term Care Compliance Toolkit

Your partner in building an effective compliance program

With more than 40 tools to help SNFs either establish or maintain a compliance program!

It’s just good business sense to have an effective compliance program—but if that’s not enough motivation, the Patient Protection and Affordable Care Act requires skilled nursing facilities (SNF) to have one in place by 2013. Available in print and electronically, The Long-Term Care Compliance Toolkit will help you develop a compliance program if you do not already have one or strengthen a program your SNF has outgrown.

You will discover practical, efficient ways to train and educate staff, perform internal auditing and monitoring checks, develop self-correcting actions, and stay on top of the constantly changing regulatory environment in long-term care. This comprehensive book will help you withstand the QIS process and Medicare audits, and improve your overall operation’s efficiency and productivity.

The Long-Term Care Compliance Toolkit will help you:

  • Save time developing MDS 3.0 and RUG-IV compliance policies and procedures by using the downloadable samples, which you can customize and implement immediately at your facility
  • 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

Take a look at the Table of Contents

  • Introduction
    • Federal Register, Vol. 65, No. 52, March 16, 2000: OIG Compliance Program Guidance for Nursing Facilities
    • Federal Register, Vol. 73, No. 190, September 30, 2008: OIG Supplemental Compliance Program Guidance for Nursing Facilities
  • Section 1: Written Policies & Procedures
    • Code of Conduct for SNF
    • Corporate Compliance Department Charter
    • Acknowledgement of Compliance
    • Corporate Compliance Post Test
  • Section 2: Compliance Officer
    • Compliance Committee Charter
  • Section 3: Conducting Training & Education
    • Compliance Training Program Outline
    • Compliance Training Program Outline: Therapy Services
    • Employee Compliance Training Record
    • Sign-in Attendance Sheet
  • Section 4: Effective Lines of Communication
    • Compliance Bulletin Board Posting
    • Hotline Poster
    • Poster on Suggestion Box
  • Section 5: Auditing & Monitoring
    • Compliance Auditing Tool for All Disciplines
    • MDS Chart Audit Tool
    • CAA Completion Audit Tool
    • Medicare Meeting Minutes Format
    • Medicare Meeting Log Part B
    • Quarterly Compliance Visit Report
    • Assessment Itinerary Announced Site Visit
    • Checklist for Unannounced Audit
    • State Survey Form
    • Quality of Life Family Interview
    • Quality of Life Group Interview
    • Quality of Life Resident Interview
    • On-site Visit Resident Review
  • Section 6: Enforcing Standards & Disciplinary Guidelines
    • Disciplinary Notice
  • Section 7: Responding to Detected Offenses
    • Assistance Form
  • Section 8: Risk Assessment
    • Grievance Policy & Procedure
    • For-profit SNFs beware: OIG taking a closer look at high RUG level


Nancy J. Beckley, MS, MBA, CHC, president, Nancy Beckley & Associates, LLC. Beckley leads a consulting firm dedicated to serving the compliance and regulatory needs of outpatient therapy providers with a focus on Medicare compliance. She has more than 25 years of experience in health systems management and consulting and has worked with integrated multi-provider health systems, academic medical centers, inpatient rehab hospitals and units, specialty rehab providers focusing on rehab agencies and CORFs, physician practices, and physical therapists in private practice.

Maureen McCarthy, RN, BS, RAC-CT, director of Medicare compliance & education, National Healthcare Associates; president, Celtic Consulting, LLC. McCarthy has been an RN for more than 25 years, with experience as an MDS coordinator, director of nursing, rehab director, and Medicare specialist. Celtic Consulting provides training on nursing documentation, Medicare billing, and the medical record review process, as well as the MDS and care planning.

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Published: August 2011