[This article is Part 1 of a 7 Part Series on Compliance Programs for SNFs, for the rest of the articles in the series, go HERE]
We’ve conquered the first four elements of a compliance program in earlier blogs. The next components of developing a compliance program are often forgotten or ignored: enforcement and discipline.
Like any effective program, there must be consequences for violating the facility’s code of conduct, policies, and procedures, including criminal conduct.
Think of the parent that threatens and threatens with no true follow-up and enforcement of the house rules. The result? A house that’s up for grabs!
An organization’s compliance is crucial in promoting and enforcing ethical conduct. We all know we’re only as good as our weakest link, so staff needs to know there are ramifications and this program isn’t just “checking a box.”
Establishing a Strong Foundation for Enforcement
Establishing a strong foundation for enforcement is crucial for any organization to ensure compliance with applicable laws and internal policies.
This foundation is built on a clear understanding of the organization’s compliance program and ethics program, which outlines the expectations for employee behavior and the consequences for non-compliance. A strong foundation for enforcement also requires a well-defined organizational culture that promotes honesty, integrity, and accountability.
This culture should be fostered through regular training and communication, ensuring all employees understand their roles and responsibilities in maintaining a compliant and ethical work environment.
Key Elements of an Effective Enforcement and Disciplinary System
An effective enforcement and disciplinary system is essential for maintaining an organization’s compliance and ethics culture. The key elements of such a system include:
- Clear policies and procedures for reporting and investigating alleged misconduct
- Disciplinary measures and actions that are fair, consistent, and proportionate to the offense
- A well-defined process for corrective actions, including training and counseling
- Regular monitoring and evaluation of the effectiveness of the enforcement and disciplinary system
- A culture of accountability, where employees are encouraged to report concerns and wrongdoing without fear of retaliation
Disciplinary Measures and Actions
Disciplinary measures and actions are essential to an effective enforcement and disciplinary system. These measures should be fair, consistent, proportionate to the offense and designed to correct behavior and prevent future misconduct. Disciplinary measures may include:
- Verbal or written warnings
- Suspension or termination of employment
- Mandatory training or counseling
- Demotion or reduction in pay
- Other corrective actions, such as restitution or community service
Key elements of an effective enforcement and disciplinary measures system include:
- Make discipline even-handed. Corporate officers, managers, and supervisors must also be held accountable for failing to comply, and compliance must be enforced consistently. In addition, managers and supervisors need to know they’re responsible for disciplining employees appropriately and consistently.
- Consider discipline on a case-by-case basis. Appropriate disciplinary actions could range from a reprimand with additional training to a demotion to termination. The incentive or disciplinary action should be proportional to the conduct to be effective. Ensure that your organization defines the procedures for handling disciplinary problems and those responsible for taking appropriate action. Additionally, organizations should implement measures to detect criminal conduct as part of their compliance efforts.
- Catch them doing something right. The program should be more than punitive; positive reinforcement goes much further than punishment for improving behavior. Incentives could include rewarding them when they raise appropriate concerns, acknowledging excellent quality of care, and rewarding helpful recommendations for improving the compliance program and its implementation.
- Make resolution swift. It’s important that the compliance officer or other management immediately investigate allegations to determine whether a compliance program violation has occurred and, if so, what steps have been taken to correct the issue. If the staff feels unheard or management is unresponsive, they’ll hesitate to report because “no one will do anything anyway.” Also, be sure to emphasize the facility’s non-retaliatory policy.
- Reroute: Look carefully at your systems based on issues that arise. In long-term care, we know “stuff” happens; however, the guidelines make it clear that a “recurrence of similar misconduct creates doubt regarding whether the organization took reasonable steps to” achieve an effective program (Guidelines, §8B2.1 Commentary App. Note 2[D]). It’s necessary to take appropriate remedial measures and analyze the root cause to determine why something happened. This may include anything from disciplining the person responsible for the improper conduct to modifying the compliance program.
- Screen employees: We must take reasonable steps to ensure that our staff hasn’t engaged in illegal activities or conducted themselves in a manner inconsistent with the compliance program. This requires that we implement employee screening procedures to check a person’s background and criminal history. This would include exclusion checks (more on that later), background checks, licensure checks, and following up with previous employers and references.
- Document, document, document: Enough said
Now comes the fun – finding our problems and correcting them!
