Creating a compliance/QA culture

Tamar Abell

Government investigations of today’s 17,000 skilled nursing facilities (SNFs) are increasing and, unfortunately, as a result so are Corporate Integrity Agreements (CIAs). A CIA is an agreement between the Office of Inspector General (OIG) and a healthcare provider or other entity as part of a settlement for alleged civil wrongdoing relating to federal health laws.

Until nearly a decade ago, CIAs focused almost exclusively on billing reimbursement and fraudulent practices. However, because the OIG’s mission is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs, CIAs related to quality of care are also on the rise. In June 2000, the first CIA that focused on quality of care went into effect; since then, more than 35 nursing home corporations entered into such agreements.

While CIAs are more common in large corporations, the government has broadened its view in the last decade to nursing home corporations of all sizes. In fact, according to University of Wisconsin-Madison Professor David Zimmerman, of the CIAs currently in place, most are with single facilities or small, corporate chains operating between two and 40 nursing homes.

The better trained the staff, the better the quality of care and the more compliant a facility will be.


To protect themselves, SNFs need to create a culture of corporate compliance and quality assurance (QA) from the top down. With new compliance legislation looming on the horizon and mounting pressures on SNFs, providers can no longer afford not to comply in every aspect. The hallmark of a truly effective compliance program includes a thorough internal infrastructure of policies regulating both financial and quality-of-care procedures that include checks and balances at every level of the organization.

SNFs need to ensure that someone is watching over the organization to ensure all preventive measures are executed and that there is a system for internal audits. This can be done by designating an employee as an in-house “compliance officer” or by outsourcing compliance oversight to a consultant.

“Having an effective compliance program isn’t going to prevent you from doing things that aren’t compliant, but it’s going to allow you to find them and deal with them before they become big problems,” says attorney Alan Schabes of Benesch, Friedlander, Coplan & Aronoff LLP. “Spend the money now to have an effective and functioning compliance program. You never want to be in a situation where the government is discovering things before you are.”

A compliance officer is critical in leading the organization’s compliance program by examining and tracking quality-of-care and financial issues. In a small organization this officer may have multiple roles, but regardless of size, the compliance officer must be respected throughout the company and be given autonomy to create an internal audit and QA infrastructure that will serve as the backbone of the compliance program.


Because there is often tremendous variation in the quality of care by facility, by unit, and even area of care within each facility, a standardized training program will be required to better ensure compliance. Consistent, targeted training for care providers, managers, administrative staff, corporate officers, facility directors, and even family members at each level will further the organization’s culture of compliance. It also goes a long way to ensure training goals are met even as staff members at all levels transition in and out of the organization. Simply put: The better trained the staff, the better the quality of care and the more compliant a facility will be.

“Training is absolutely essential because compliance is necessary at all levels of the organization right down to the caregivers that are the certified nursing assistants,” says Zimmerman. “This is not something that is naturally taught in technical education programs or nursing schools, so organizations need to ensure that all individuals in their employ are aware of what the rules are with respect to compliance with regulations.”

When developing an effective training program, ask yourself the following questions:

  • What training have we done and how do we know it has been effective?

  • Was everyone present who needs to be there?

  • Did we do a follow-up?

  • Is there a test? Did everyone pass and understand the criteria?

“Effective programs are all about training,” says David Hoffman, president, David Hoffman & Associates, a law firm that focuses on legal, regulatory, and clinical compliance. “The question then becomes, How do we evaluate our training programs? A provider must ensure that qualified educators are performing the training programs and that staff understands the message that has been presented. There must be some evaluation process to ensure that the training was effective, including the evaluation of clinical competencies associated with the training. That’s critical. Our expectation of effective training is that it will lead to meaningful intervention.”


AristaCare, a regional provider of subacute, post-acute, and LTC services, quickly realized that more concise and frequent training better equipped employees to be compliant and the company quickly saw the impact on surveys. “When you standardize training, you see improvements in compliance. The levels of success people demonstrate in training trickles down to compliance; they know what they should be doing and are doing it,” explains Reneè Pruzansky, AristaCare’s chief operating officer.

Within three months of implementing online training, AristaCare experienced a 36% increase in patient satisfaction. By year end, AristaCare saw a 57% increase in certain key areas in patient satisfaction over the previous year and a 42% increase in customer service directly related to the customized customer service modules. Equally important to customer satisfaction was the improvements in the company’s annual survey ratings. AristaCare examined survey data dating back three years and recognized trends in infection control, medication pass, falls, documentation, and managing difficult patients. Consistent, mandatory training enabled them to reinforce the important areas where they were getting cited and focused on improving the standard of care in that area.

As the penalties and liabilities for insufficient oversight rise and the 2013 compliance deadline approaches, SNFs will need to determine the best way to incorporate compliance into the day-to-day operations of their facilities.

Tamar Abell, MA-CCC-SLP, LNHA, Principal of Upstairs Solutions, is a third-generation nursing home owner/operater who has managed 10 communities over the past 15 years. Upstairs Solutions offers more than 130 online training modules and a learning management system to assist in tracking employee training and licensures. Call (866) 763-4500 or visit for more information. Long-Term Living 2011 May;60(5):36-37

Topics: Articles , Regulatory Compliance