Episode 115:
Top Takeaways from New Skilled Nursing Facility Guidance

Episode Transcript

Hello, welcome everybody to another episode of Compliance Conversations. I'm CJ Wolf with Healthicity. And today we're going to be talking about some of the OIG guidance. I have a real expert here on some of that information, especially some of the recent ICPG that was recently published. But before we get into our topic, let me tell you who our wonderful guest is, Paige Pennington. Paige, welcome back. I know you've been on the podcast before. 

Thank you for having me. Looking forward to speaking to you at length about the OIG's ICPG. 

Yeah, we're so excited to have you. And you've probably done this before, but it's probably been a while for our guests. So we'd love for you just to tell us about yourself, introduce yourself, what you do, kind of your background, whatever you're comfortable sharing. We'd love to hear that before we jump into the topic. 

Hi, everybody. Thanks for tuning in today. My name is Paige, as CJ mentioned. I'm a co-founder of a compliance consulting firm called Compliagent. We've been around since, goodness, 2010, 2011-ish. We work with all types of healthcare providers on building out their compliance programs, helping them maintain it. Sometimes we get involved with overseeing corporate integrity agreements or serving as independent auditors. Our real Relationships with our clients really depend on what their compliance needs are. Sometimes we meet folks that are at the very beginning of their compliance journey and say, where do we start? And other times we're getting more involved in a very sophisticated model where they've been at it for a decade or two and just want an outsider perspective on compliance. How do you think we're doing? What can we improve? So we meet our clients where they are across the healthcare spectrum. With that being said, though, my expertise is certainly in the post-acute care side. I work primarily with long-term care facilities, skilled nursing, nursing homes, home health hospice. So Hence why today I'm going to be focusing on the industry-specific guidance for skilled nursing facilities, because that is where I spend about 85% of my time. 

Yeah, and we're so excited to hear from you. And for those of you who've been listeners and you partake of a lot of the resources posted on Healthicity's website, you'll see, maybe we can even find these links, webinars that Paige has done with us. She's an absolute expert in this space and just one of the nicest and best people to work with. So I highly encourage you to consider her and their services. They're great. So Paige, let's jump into this ICPG. And let me just kind of give the folks some background. Most of our folks are compliance folks and audience, so they already know this. But as we all know, the OIG has published a new general compliance program guidance document, which we've been talking about for over a year and a half, I think now. But at the end of last year, they published their first ICPG. They promised that they would publish these industry guidelines. kind of sub segments of the healthcare industry specific guidance. So, and that's what we're gonna talk about. And so Paige, tell us a little bit about this recently updated, you know, ICPG for nursing facilities and what your initial thoughts are on this. 

Yeah, I think it's telling that the OIG picked skilled nursing as the industry, to focus on for their first ICPG because we got the general compliance program guidance that is broadly applicable to any type of provider in the healthcare side. That could be adapted for large organizations, small organizations, home health, hospice, skilled nursing, hospitals. And that came out in 2023 and that was, you know, meant to be what I would say provider agnostic, not focusing on anyone and is very geared toward those seven elements of compliance. And we knew that industry specific stuff was coming. But the fact that skilled nursing got the first guidance, I think tells you a little bit about what the government views as their priority list for enforcement. Skilled nursing facilities have the most recent guidance out there. So The previous round of guidance was issued by OIG 1998 through 2008. The skilled nursing guidance came out in 2000 initially and was supplemented in 2008, technically making this industry the most recent guidance from the OIG. So you would think that OIG would naturally want to update its guidance that they issued in 1998 before they updated the more recent 2008 guidance documents. 

Exactly. 

It's not the approach they took. So, you know, there are, you know, guidance documents for hospice and labs that haven't been touched since the 90s. And those were not prioritized. So I think that we will see more enforcement in the skilled nursing industry. Bad for providers, kind of good for me as a consultant. But, you know, I mean, it's... It is definitely the tone of we have concerns about this sector of the industry more so than other sectors. The OIG recently updated its website to specifically say that other industry guidance for hospitals, clinical laboratories, and Medicare Advantage programs is expected in 2025 with hospice and pharma to follow sometime later, 2026, 2027. But Medicare Advantage doesn't even currently have guidance, period. Not from the 90s, not from any time. So being prioritized over Medicare Advantage, which is a huge payer program, is surprising and probably fairly concerning for a lot of my skilled nursing clients. So I would tell providers in this sector of the industry, dot your I's and cross your T's. 

Absolutely. That's such a great perspective, Paige, about and I hadn't really thought about it that way, that they did have, the skilled nursing facilities did have the most recent published guidance in the old methodology, right, through the Federal Register in 2008. So yeah, interesting that they're visiting that one first. Great, great perspective on that. So tell me what you think, were there any surprises? So maybe what was not a surprise? What was a surprise when you first kind of read through the ICPG? 

Yeah, I liked how the OIG approached the guidance in their rebranding of these older documents and kind of re-imagining how they're divided. I thought it was smart to pull out the seven elements so they weren't repeating the same content in each industry-specific guidance document. So organizationally as a type A person, I'm like, oh, this makes sense. You have a general one that everyone should look at, and then you have risk-based program guidance that leaves out largely the seven elements stuff and focuses just on the risk specific areas that they hope providers are focusing their training policies and monitoring and auditing efforts on. So organizationally, I thought, good, it was a nice cleanup, great. The federal government isn't always great at streamlining, but I thought that this was a very appropriate way to bifurcate those two guidance approaches 

That being said, the usual suspects are still there, right? 

We see risk areas in staffing and medication management with a focus on psychotropics and antipsychotics. 

We see the mention of abuse and neglect as a concern, and then obviously accuracy of documentation to support billing under the Medicare program. So these were in the 2000 documents. the 2008 documents, they are in this document. And I suspect in 10 years or 15 years from now, he'll be in the next iteration as well. So that stuff doesn't altogether surprise me. I think that they did a better job in this document of giving practical examples versus citing deregulations and talking about things in theory. With each of these sections, they really did break down, this is our concern, this is how we see it happen, here are some recommendations for what we think you should be doing as part of your compliance program. So yeah, on that respect, okay, great, nice update. There were a handful of topics I was a little bit surprised to see in this document and not a negative surprise and like, I don't think this is an issue in the industry. But I was surprised to see it was at the level of the OIG feeling it was worth mentioning. So, you know, some of this stuff I was like, oh, this is, you know, on the OIG's radar. That's interesting. Maybe I as a consultant to skilled nursing facilities should call this stuff out a little bit more and focus on it more than I have historically. So the first one, that I was kind of surprised to see was this recognition paragraph about the changing demographics and the patient population, the acknowledgement that skilled nursing facilities are taking on younger populations with higher acuity and also a lot of more behavioral or mental health needs than has historically been the case in the nursing industry. So, you know, I think to the general public, they hear nursing home and they still think that like grandma's going to the nursing home so she doesn't live by herself and they treat it in their minds more like a independent but assisted living type of setting, not high acuity post-surgery with like complex medical comorbidities. And that's just not what the industry is. Like we are really seeing a high push on acuity, a ton of behavioral and mental health needs. And so I thought it was nice that the OIG called that out, albeit this is a guidance document. So it's not like they solved a problem for us by saying, here's how to address this. It's more like we're at least acknowledging the problem or acknowledging that you guys are faced with these problems and are becoming more akin to a hospital than the assisted living or independent living side. So I thought that it was surprising that they acknowledged it in this document because I wouldn't necessarily say it's a compliance risk, but they did tie it into the requirements of participation. specifically to the facility assessment piece, which was recently updated by CMS in August of 2024, and said, in consideration of all of these more complex things that you have to consider when you're admitting your patients, make sure that you have the capacity and ability and the resources to provide appropriate services. So if you are taking on patients with behavioral needs or mental health needs, make sure your staff is getting that training. So this really, I think dovetails with the idea of not only sufficiency of staff by number, which we know is a whole separate issue in the skilled nursing industry, but also the competency of your staff to appropriately care for the resident population that you are choosing to admit. So I thought that was, you know, consistent with some of the stuff that we've seen from CMS. I didn't necessarily expect to see it in this document as a risk area of competency and complexity of the patient population. 

Yeah. And on that note, Paige, so it was interesting to me, and maybe you were going to talk about this later, but they talk about how, oh, there's lots of turnover in staffing and nursing facility. Like they mentioned all of these hard things in the industry, right? And basically I just felt like, okay, they're pointing out the obvious and they're just kind of saying, this is hard, but you got to deal with it. I don't, did you come away with that? It felt like I'm the staffing. I 

think that is kind of the tone throughout this document. There are a few places where they give recommendations or share. These are what other providers have done that leave you as successful solutions. 

Yeah. 

Certainly not in the realm of staffing. I mean, Every nursing home operator nationwide is waiting to see what the current administration does with the proposed minimum federal staffing mandate rule that is going to roll out in pieces. It's the shortage of qualified nurses in all different levels, RNs, LPNs, and your nursing assistants. is a concern in the industry. And it's not that people don't want to hire these individuals. It is literally that finding, hiring, retaining. I don't have a perfect solution. Everyone wants to talk to me about this and say, what should we do? And there's no like, here are your six steps. If you do this, you'll be successful and you'll never lose a nurse again. I wish it was that easy. But yeah, a lot of times staffing comes up as it ties into these risk areas. but there's really no solution here. It's like, do stuff to promote retention. And it's like, what is the stuff that you want us to do? 

Exactly. Okay. I'm glad I wasn't the only one who kind of read it that way. And sorry to interrupt. Go ahead. Any other like surprises that you were talking about? 

Yes, certainly. Full of surprises. Okay. I have a few other areas that are on my short list of call-outs for this particular question I was anticipating. The next one was related to care planning and activities. So care planning as a potential risk area was included in the 2008 guidance. So not wholly surprising, but the lumping it in with activities was a little bit of a nuance that I generally, again, don't think of the OIG honing in on. When I think of OIG, I'm thinking really high level, like false claims, inaccurate billing, anti-kickback. I'm not thinking the OIG cares so much about person-centered care. And well, I retract that statement because they certainly do because it's been, it was really woven throughout this document and a lot of the quality areas they brought back to align with CMS. So I think the two agencies really are starting to mirror each other in terms of this guidance. Now, aligning more with what CMS pushed out in 2016 with the big revision of the ROPs on the person-centered approach to care. So I thought that that was nice, but again, surprising to see that care planning and appropriateness of activities. And at one point the OIG even, you know, I'll quote this from them, says that engagement in socially and cognitively enriching activities is an essential part contributing factor in a resident's quality of life and well-being. 

Yeah, that was so interesting. And they put it in the context, I think, if I remember right, they prefaced this whole thing, kind of like what you were saying before about this changing kind of population. They talked about how nursing facilities are not just about taking care of the physical needs of somebody medically, but it's also often their home or at least part-time or temporary home. And so they talk about it as this is their home and well-being and activities. 

Yeah. 

For sure. That's exactly how they posit this, you know, whole section is don't take care of only the clinical needs. It is for all of the folks in long-term care. They'll be familiar with this. It's the psychosocial wellbeing of the individual. So it is the whole person, not just the medical or clinical side that the expectation is the nursing home is being paid to promote these things. So it's, I didn't expect it to be in here. I view this as more, like if you gave me the sentence and said, which agency did it come from? Oh, I guess it would have been CMS. This feels very survey quality of life. I'm surprised it made it into the compliance program. But there was a big focus on quality as a component of compliance in the general compliance program guidance that was issued in 2023. So maybe I shouldn't have been so surprised that OIG is leaning a little bit more into like person centered care and preferences and dignity. But this was not the tone of their 2000-2008 guidance documents. It was nice, but still surprising to see here. 

Gotcha. 

Let's see. What else? What else did I think was surprising? 

Anti-kickback statute got a big upgrade. And by upgrade, I mean it used to be a short section in the statute. previous guidance documents. It's now a very large section of the guidance. So I think they called out maybe like seven or eight different areas of risk under the anti-kickback statute in this industry specific program guidance that just came out in the previous guidance. I got to mention, you know, and we talk about this as it relates to physician contracting and how the you market to your referral sources. And that's typical stuff that we talk about with our clients. There was a lot of focus on the contracting piece. So for me, I'm, you know, my wheels are spinning thinking I should be doing more with my clients in this area because the OIG is really leaning into the arrangements with other healthcare providers. So there was a lot more discussion about, you know, free or discounted goods from other providers, the contracting arrangements with hospices, particularly the rates that are paid to the skilled nursing facility for the different levels of care, arrangements with long-term care pharmacies, joint ventures. So the contracting piece and the rate setting played a much more significant role. There was also some interesting discussion about hospital arrangements that I don't recall seeing in the 2008 guidance that come up pretty regularly for me with my clients. So I was surprised that these were raised as red flags and is now really making me wanna circle back with my clients to take a secondary review on some of these documents. Now having insight into what the OIG is viewing as risky behavior so i want to spend a little bit of time calling each of these out because i think that these are things that most nursing home groups are doing in some regard maybe not in all their facilities i think it's probably a little bit dependent on the market my guess would be in bigger metropolitan areas these topics come up but the first one was related to payments to accept a discharge patient from a hospital so The concept being the hospital might offer to supplement the payment to the nursing facility because the clinical care that the patient needs is going to be more expensive than what Medicare might pay out under the PDPM HIPPS code. So to get the nursing facility to accept the patient so the hospital can open the bed, the hospital says, we will basically subsidize your Medicare payment. Please accept this patient. and move this along for us. So the OIG calls this out specifically and says, there is no safe harbor protection available for this type of arrangement under the federal anti-kickback statute. So be careful. They don't tell you how to structure this arrangement. They just give you a warning of, be careful we're on to this and they're not wrong i have plenty of clients who get these letters of understanding uh or you know one page agreements that say hey this patient's on this very expensive medication it's not carved out under consolidated billing we will cover the cost we just desperately need to open this bed and no one else will take this patient that's basically the scenario that presents itself and it's not uncommon but it is a little bit of a red flag that the OIG is calling this out as a concern. So I'm certainly going forward with my clients, going to do some education around this area, asked to be looped into the conversation whenever these issues come up in the future. So I thought that was interesting because I don't recall that being in the last guidance document. 

Yeah, that was really specific kind of call out. It's like they 

had something that they were, pointing to and somehow this had come up and they haven't even issued an advisory opinion on something like this, which you might expect. But I'm like, how did they become aware? Why is this on their radar? And are they going to do something about it is the bigger question. The second item under the hospital arrangements that they carved out as a potential concern was reserve or bed hold payments basically made by the hospital to hold a certain number of beds. And sometimes we see this not with the hospital, but with a health plan. This health plan plan wants to reserve five beds in this building. So they always have a location to discharge their patients to because they're contracted with this facility as a provider. So not uncommon. I see this pretty regularly. The OIG does note that there is a proper way to structure this arrangement, albeit They don't tell you what that is. But what they do say is what they're concerned about. So they say there is a good way to do this in a way that we would not say that you are liable under the anti-kickback statute. You figure that out on your own. What we will tell you is that we are concerned in double dipping. So the nursing facility getting paid while the bed is actually occupied by another patient. So they want to make sure that there is a process to make sure that doesn't occur. They are concerned about the hospital paying for more beds than they legitimately need. So at any given time, maybe this hospital or health plan, for example, only ever has three or four patients in that building, but they're paying for 10 beds. That would be suspicious. And then the other piece is excessive payments. So even if the amount of beds that they're asking you to reserve is excessive, you know, consistent with what your average census is for that payer or that hospital at that building. What are you paying to reserve the bed? Is that fair market value? And if not, why? So those are some things that now with this call out on this topic in the industry guidance, I certainly want to in the future look at these contracts as they come across and say, okay, we need to make sure that this rates that they're reserving the beds for is consistent with your Medicaid rate or your private rate for just room and board or whatever it is. But we have to figure out how we are basing this rate to say it's fair market value and not just accepting a dollar. 

Yeah, so interesting. Sorry, I didn't mean to interrupt. Go ahead, finish your 

thought. No, I think that was the end of my thought. I was just going to reiterate. So I think it's really important that providers go back and look at these arrangements because if they have them and they haven't been reviewed in a handful of years, the fair market value rate not be there anymore and they might need to adjust it up or down, probably up. But it's something that we have not seen commented on, although it's certainly an industry practice that exists. 

Yeah. I want to ask you a follow-up question about kind of this whole anti-kickback section. In one moment, we're going to take a quick break, everyone, and we'll be right back. Welcome back everyone from the break. Paige has been telling us about, you know, these very specific kind of call-outs in the anti-kickback section. And Paige, I'm just wondering maybe at a general level, like this seems like they've, they've, they've gone pretty deep into some very specific examples. They had another one that you were talking about that you and I communicated about this, the pharmacy consultants and all those sorts of things. Do you think this is going to be indicative? Like I'm trying to predict like what the guidance might be for hospitals and physicians and labs. I'm curious. I'm thinking this might be an example of they did some pretty specific AKS risks for this ICPG vaccine. I'm hoping and thinking they'll do similars for other ICPGs. What are your thoughts on that? 

I would hope so. I mean, I hope that they didn't give all of the risk and say, we feel like this is the nursing home's problem to solve. You know, it's a 50-50 arrangement. So everything that's mirrored in here, I would expect to see in the hospital guidance or in the hospice guidance or If it wasn't, I feel like that's quite unfair to say nursing homes solve the problem when there are two providers to these arrangements. But I will say that I think it's an interesting approach to the AKS category of risk, because like I said before the break, when I'm talking about AKS with my clients, I'm primarily focusing on no we don't give gift cards to the computers for referrals or like these are appropriate ranges for professional business dinners to talk about quality and this is how we structure our physician consulting arrangements our medical directorships and how we document so those are typically the areas i'm talking about with my clients when it comes to anti-kickback statute risk this focus was so much heavier on contracting. So I feel like, okay, I need to go work with the procurement department or make legal who is reviewing these contracts aware of these risks and maybe come up with a one-pager or half-pager about compliance considerations. Please run these by me as your consultant when these issues come up. Don't just look at the boilerplate legal terms of the agreement. You have to be mindful about X, Y, and Z. So I feel like it became a little bit more sophisticated than I typically approach with my clients. So that puts something on my to-do list for sure going into 2025. Yeah, 

I'm so glad you brought that up because, you know, so many times like people will tell me, oh, well, our legal department, you know, reviewed this agreement. It's usually not the agreement and what's in writing that's the problem. It's the backstory. It's are you actually, first of all, doing what you said you're doing in the agreement? So you can't just write an agreement and say you're going to do X, Y, and Z, and then you do A, B, and C. And so it's not just, oh, legal reviewed the agreement. Well, has anybody reviewed the situation or the context, right? Like what's going on behind the scenes? You didn't tell me that you guys were also doing this little interaction behind the scenes. That didn't make it into the agreement because if it had, it wouldn't have been cleared. So I'm with you. I think it's so interesting that These are very kind of contractual types of arrangements that have been highlighted here. 

Yeah, there's definitely work for any nursing home chain that has like a general counsel that is in charge of reviewing contracts or maybe even a procurement department that is responsible for approving these arrangements. Compliance needs to be working closely with them and giving them a short list of, these are the issues I want you to spot check. I don't need to review the whole agreement. I'm not reviewing, for example, like the indemnity clause. That is of no concern to the compliance officer. That is a legal function. Or the arbitration clause or the termination language. The compliance officer is generally not concerned with that. I totally get that that is a legal function and I don't want that to come to compliance. But I do want compliance to be at the table to call out some of these real compliance issues around fair market value and clear language in there that says we won't do X, Y, and Z. And the anti-kickback statute language should be in there. So there is a compliance piece to these contract workflows within an organization. And I think this is really telling the compliance officer, if you're not already putting yourself at that table, you need to insert yourself in these discussions. 

Yeah, I agree. And I'm going to predict that other ICPGs that come out are going to kind of have a similar theme, that the specifics or the risks might be like the scenarios might be slightly different. But the theme of what we just talked about, I think, is going to be in those. So let me kind of shift gears a little bit here. And you've shared a lot of really great specifics. And you've already kind of shared a little bit of this. So if you don't have more on this topic, that's fine. But what does all of this information kind of inform you about how you're going to approach and how we should all approach developing compliance and ethics programs? I mean, you mentioned a little bit about it, but anything else? Of course I have additional thoughts. 

Speaker 01 

30:54 

So, yeah, I think that this is not your seven elements document, right? That's a general compliance program guidance. But that being said, this document really shapes how you approach, I think, two of those seven elements. One is the design of your program, the who is participating in these discussions. How does the compliance program get involved in areas that have traditionally been like, Marked as this is clinicals role and responsibility, or this is legal function. And I think the other piece of it is obviously the auditing and monitoring element and risk identification. So for me, I was, you know, giving our team a pat on the back of, I think we've been doing this. The right way, everything that we approach with. structuring a compliance program, education, designating roles and responsibilities really jives with what the OIG is putting out between the general and industry-specific guidance documents together. So I feel like we are on the right track in terms of structure. Like I said, a few points throughout this conversation, I definitely have some items on my homework list that I want to circle back to our clients to reinforce or maybe do an audit in an area where we haven't really taken the initiative as the compliance team to audit before and kind of delegated off to people. But for me, I think one of the big takeaways is structure. So compliance has to have a seat at the table. I think that for me, especially when starting with a client that is building their program, not coming into someone who has an established program, but someone who's building out their program or formalizing it for the first time, it's not uncommon for us to get pushback from other disciplines like IT or particularly the clinical team saying, we don't report to you. We're our own vertical within the company. I report to the president or the CEO, kind of stay in your lane compliance people. And I get it. It's unusual for you to be asked to report to someone who is not your direct supervisor. And sometimes, you know, egos can get involved. These people have been experts in their fields for likely decades. So sharing your work product with someone else in anticipation of getting feedback or notes feels uncomfortable. But for me, it's something you have to overcome to have a compliance program that is actually effective and working in the way that the OIG expects it to work. Now, for example, let's say I have a regional MDS consultant and this person is going to be more skilled at reviewing an MDS and telling you if you have coded it accurately based on what's in the medical record than your compliance officer. I expect your compliance officer to be a generalist and your MDS consultant or your regional MDS consultant to be the expert. That being said, if that consultant finds a error in the coding of a standalone MDS assessment when they were doing a proactive, you know, sample size, randomly selected audit, and they tell the facility-based MDS person, oh, I found this error, you know, correct it and resubmit a modified MDS assessment. That might be the end of that. Yeah. No one else is told about that. But if the compliance officer through the compliance committee or whatever other channel they have for communication is told about an improperly coded MDS, as a compliance professional, I'm thinking, okay, I have a few questions. Was this isolated? Like what was the cause of the error in coding? Was this a misunderstanding of the rule and therefore is going to affect other charts or other MDS assessments that also need to be corrected? How patterned was this? What's our look back period? Are we going back the six years under the Medicare A and B 60 day refund rule? Should we be getting legal counsel involved right now to privilege our internal due diligence? to determine what our overpayment liability is. So I'm not saying what the regional did was incorrect in directing the facility-based person to modify the MDS. That's absolutely what they need to do. But there is a very big conversation that that triggers that when someone who is focused on their specific role acts alone and doesn't information share, you miss out on the bigger picture and the actual false claims risk that comes with not sharing that information. So I think it is a hurdle for companies who are developing and building their compliance program to get past some of the breaking down of the walls and information sharing and integrating and recognizing compliance as its own discipline and the compliance officer as a person that has a distinct skillset to help the company and not feel like it's, oh no, it's big brother watching my every move, but really acknowledging that you approach this very differently. Like we are working to solve the same problem, but we have different experiences and skill sets that we're bringing to the table to tackle it. So I think that that is something that these two documents say you need to do a really good job at making sure these organizations walls are not built up between the different verticals within your company. So I think that that is something that helps me feel that as consultants, we've done a really good job. That is the approach we've always taken. It is information sharing. So I felt like that was reinforced throughout these two documents. And that kind of, I guess, takes me into this discussion at the end of this ICPG that the OIG has about who your compliance officer is. And I thought that this was interesting because in, at least for skilled nursing facilities, we have a CMS mandate to have a compliance and ethics program at F895. Slightly different requirements if you're five or more buildings, slightly lighter requirements if you're four or fewer buildings, But for the larger groups, you're expected to have a compliance officer for whom compliance is a major job responsibility, although major job responsibility is not defined. The OIG in this document in the industry-specific guidance says this person should have sufficient experience in managing both compliance programs, but also have involvement in quality. It's hard for someone that has no idea what an MDS is to identify when there's concerns, for example, or that doesn't really understand the clinical side or the care that we give to identify when concerns rise to the level of substandard care. So there does need to be some cross-training there. I think it's probably easier for chains of nursing homes that have 20 plus facilities to not only budget for this position, but they also probably have a lot more people with these skill sets that they can promote into the role internally versus sourcing externally. I think it is particularly hard for the people or the groups in five to 15-ish locations budgeting to have a full-time compliance position, or if not a full-time compliance position, giving someone who already has a full-time role an additional responsibility for the compliance program and giving them two areas to oversee. So I just think that it is something that the OIG notes in here that really does impact how you've structured your compliance program because of their emphasis on quality and really integrating these programs as not quality you live over here and you never have to talk to your compliance officer because you do two very distinct functions. It is making sure that your compliance officer has the requisite authority to do their job and the knowledge and experience to identify the red flags within the quality of care, discipline, or vertical of the company. 

Yeah, Paige, those are great insights, such great insights. And I'm glad you kind of talked about how it's the two documents going together. I think the OIG has really, designed it this way, that the GCPG is not just something you gloss over, but that's kind of the prerequisite for reading your ICPGs. And so really, I appreciate the way you kind of paired those two together. We are kind of coming towards the end of our time. But I wanted to give you some time to kind of share last minute thoughts, any takeaways, or maybe something I didn't ask that you feel is really important to share. 

Yeah. 

I would say that this is probably a good time for anyone with an established compliance program that says, oh, we have a good program in place, we have a really qualified compliance officer. If you haven't done a comprehensive compliance program review, the timing would be right. Like I said at the beginning, I think there's going to be an industry focus on enforcement for skilled nursing facilities. go back, make sure your I's are dotted, your T's are crossed. If you rolled out this program and haven't really looked at your documentation to see how you're recording it and supporting it, it's timely to do that now. Specifically, I would focus on the person sitting in the compliance officer role to make sure, like I said, they have the requisite authority, independence, and experience to carry out the role. At a minimum, I would recommend starting by looking at who you have in your compliance officer role and making sure that person has the requisite authority, independence, and experience to carry out their job responsibilities. Second, I would make sure that you have a really integrated compliance department with those other disciplines, making sure that your compliance committee is effective and that the folks participating in those meetings are reporting relevant information and doing data analysis and trending. And then I would go through the table of contents of this industry specific guidance document and say, what are we doing in these areas? And then document how you risk rank them and prioritize them, what you're doing for auditing and make sure that you are ensuring that should the OIG or DOJ knock on your door, you have good sufficient documentation to show your good faith efforts that you are responding appropriately to the guidance that the government's giving you. in your monitoring and auditing programs. 

Yeah. And, you know, I think that at a minimum, we should be taking like these ICPGs and any specific risks. Like, you know, we spent a lot of time at the beginning talking about AKS and those specific call-outs. We should at least on our risk assessments be looking at every one of those call-outs and quantifying how big of a risk is this for us? Or if you could substantiate, you know, we don't, Get involved in that. We don't have these pharmacy contracts. We don't have this or we do. And to this level, like at a minimum, it feels like our risk assessment should at least be commenting on each of the call outs in these ICPGs. It doesn't mean those are the only risks. Of course, there may be others, but it feels like at a minimum, we should be addressing those to your point. 

Yeah, I 100% agree with you. I really literally feel like you could take this table of contents and cut and paste it. And then in the column next to it, right? Like, is this a risk? Yes, no. 

And why? What is it? 

For example, you don't have a joint venture. So you write no and you do nothing. Great. But we considered whether or not it was a risk. And then for any of the yeses, it's How high of a risk is this, you know, to be really basic, high, low, medium risk? And when are we going to do an audit of our risk based on the priority? And I think that that is if you don't have a formalized written audit program, the basis for developing it. 

Yeah, such great advice. Paige, you're always amazing to talk to and always share such great insights. And you have all of the knowledge, but then also the practical experience. I know you're actually working with clients in all of these areas. And so you've seen what works and what doesn't work. And so really appreciate your willingness to share your expertise today. 

I'm happy to be on here and share that feedback. I think that there is probably a lack of folks that really understand the skilled nursing industry specifically in the compliance discipline. So I enjoy talking about this and raising the awareness around the risks for this segment of the healthcare industry. So thanks for having me. 

Absolutely. And for those listening, we will include Paige's contact information in the show notes. So if you have questions or if you feel like you need her help or Compligents help, you can have that contact information. And thank you to all those who are always listening. We always ask this at the end. If you have a topic that you want to hear addressed, please share it with us. If you have a speaker or an expert or somebody that you know that would make a great guest, please pass their name along to us. And thanks Again, everyone for listening. Until next time, take care. 

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