A question facing every compliance and ethics program (“compliance program”) is how to best structure the program to achieve optimal effectiveness (i.e., how to structure it to prevent and detect fraud, waste, and abuse, which is the objective) most effectively. For multisite organizations, one structure option involves the use of compliance liaisons. Compliance liaisons are generally not employees of the compliance program but are individuals with an operational role—sometimes in a higher-risk department or off-site location—that function as a liaison between the compliance program and operations stakeholders throughout the organization. Compliance liaisons can help bridge a gap over which many compliance programs struggle: practical engagement with and impact on operations’ departments and personnel. Compliance liaisons—while not employees of the compliance program—have a formal or informal “dotted line” to the compliance program to help the compliance program function more effectively and have influence on operations staff and teams “in the field.” Implementing a compliance liaison model effectively can increase engagement with individual departments and/or off-site facilities. Some may feel very removed from the compliance program because of their physical distance from or lack of engagement with the compliance program.
While some types of organizations have chosen a compliance liaison model to promote compliance program effectiveness for skilled nursing facility (SNF) operators with five or more facilities, this is now a requirement of participation under Phase Three.
The regulation
The Centers for Medicare & Medicaid Services (CMS) first published the Requirements of Participation for long-term care facilities in 1989. The Requirements were recently updated in a rule that became final on November 28, 2016.[1] These recent updates to the rule include modernization of requirements “to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety.”[2] In addition to updates based on theory and practice, the rule also includes—among other things—specific compliance program requirements found in section 483.85 of the rule. While based on the traditional seven elements of an effective compliance program, the prescriptive requirements of the final rule have several nuances to tailor the elements to the SNF environment. Different requirements are also based on the organization’s size, resources, and sophistication. Organizations with five or more facilities have certain additional requirements, including designation of a compliance officer at the corporate level and designation of compliance liaisons at the facility level.
While the regulation requires the compliance liaison role for organizations with five or more facilities (while not required for an organization with less than five facilities, it may still be a best practice to implement), the role is not a defined term; there are not prescriptive job responsibilities included in the rule beyond “[a]t a minimum, these liaisons should be responsible for assisting the compliance officer with his or her duties under the operating organization’s program at their individual facilities.”[3] ( 80 FR 42220 ). Each organization must determine the compliance liaison’s qualifications, job description, and roles and responsibilities.
Roles and responsibilities
Before proceeding with the qualifications and considerations when selecting compliance liaisons, it is important to identify the compliance liaison’s responsibilities in assisting the compliance officer with the program at the individual facilities. Since the objective is to assist the compliance officer with the program at the facility level, the organization should contemplate what duties the compliance liaison would have that could extend the reach of the compliance officer and increase the impact and effectiveness of the compliance program at the facility level. Obvious responsibilities include those that the compliance officer or staff person would have if they were present in the facility; the compliance liaison is, in effect, the in-person, “boots on the ground” extension of the compliance program. Responsibilities may include:
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Serving as the in-person resource for compliance-related issues and questions
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Representing the compliance program in facility-level meetings
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Coordinating with the quality assurance and performance improvement (QAPI) committee
in-person, including one-on-one and in-group settings, and communication about and promotion of the compliance program including program updates or initiatives
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Encouraging transparency and reporting
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Helping with in-person portions of investigations
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Performing monitoring of higher-risk functions in accordance with the work plan and/or auditing and monitoring plan
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Incorporating the facility and hazard vulnerability assessments into the work plan
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Conducting in-person compliance training
In addition to the duties beneficial for the compliance liaison to perform as the in-person extension of the compliance program, the liaison can participate in compliance risk assessment initiatives; it can provide insights into the effectiveness of the program at the facility level and, further, make recommendations for needed compliance program evolution considering lessons learned.
