[This article is Part 2 of a 7 Part Series on Compliance Programs for SNFs, for the rest of the articles in the series, go HERE]
The last blog reviewed the requirement for developing compliance policy and procedures; now we’ll tackle the next requirement: communication!
As we’re seeing, an effective compliance program is a team sport – truly a group effort. From the team owners lending support and creating a positive atmosphere down to every member of the team (even the beer vendors!). How can your organization create a mechanism that gives all staff, visitors, vendors, etc. a safe way to express their concerns?
The third component of an effective compliance program is developing effective lines of communication. You’re creating a culture that values ethics and doing the right thing. For your program to be effective, employees must be able to ask questions and report problems; you want an environment that encourages and rewards communication within the organization. The corporate compliance officer is the point person to develop your communication systems.
The organization must determine an effective mechanism or combination of approaches that allows employees, residents, visitors, etc. to report their concerns, including an option to report anonymously. Best practices for anonymous reporting include establishing a hotline, outsourcing the hotline, a suggestion box, emails, or establishing a written method of confidential disclosure.
A word about hotlines: they work! A hotline allows employees to report their concerns 24/7 and gives them a place where they’re always heard. As managers, we often feel like our heads are spinning with everything that must get done, and we may not be as accessible to our staff as we’d like. A hotline gives employees a safe place to report their concerns – even concerns about the manager with the spinning head!
To be effective, the hotline must be well-publicized in the facility and made readily available to employees, contractors, residents, and family members. It must be clear that there are non-retaliation policies to encourage communication. You can do this with conspicuous postings of the number throughout the facility with a picture of the compliance officer on it. (I like including a picture to remind the caller there is a REAL person on the other side listening and helping resolve issues.) Other ideas include circulating a wallet card with the information, including it in the admission packet, reminding residents at council meetings, and/or including it with pay stubs.
When does a hotline NOT work? When there isn’t appropriate follow up. The OIG recommends creating an intake form for all compliance issues identified through the reporting mechanism. The compliance officer should maintain a log of calls, including the investigation and its results. The intake form could include the date the potential problem was reported, the results of the internal investigation, the corrective action implemented, the disciplinary measures imposed, and outcomes.
The Grievance Log on the SNF Metric portal is a great tool to meet the criteria for tracking compliance and grievance issues. This simple-to-use app allows you to record all grievances in one place with an easy way to track resolution and follow up. This can be done per facility or as an overview of your entire organization, with the ability to drill down to each grievance and view its status. However your organization chooses to track, just be sure you have a policy and procedure for being accountable!
One last thought on confidentiality. That’s always a tricky one when investigating complaints and grievances – and we’re often tempted to avoid investigating those. While the nursing facility should always strive to maintain the confidentiality of the employee’s identity, the OIG states, “It should be clarified that there may be a point where the individual’s identity may become known or may have to be revealed in certain instances … The OIG recognizes that protecting anonymity may be infeasible for small nursing facilities.”
- Is my communication plan available and being used effectively?
- Are the findings of the compliance hotline shared with the compliance committee with recommendations for follow up?
- Do my employees know of the organization communication plan and do they believe their concerns are being addressed promptly?