Office of Inspector General’s Compliance Program Guidance for Nursing Facilities

E. Developing Effective Lines of Communication

1. Access to the Compliance Officer

In order for a compliance program to work, employees must be able to ask questions and report problems. The first line supervisors play a key role in responding to employee concerns and it is appropriate that they serve as a first line of communications. In order to encourage communications, confidentiality and non-retaliation policies should be developed and distributed to all employees.⁹⁴

Open lines of communication between the compliance officer and nursing facility employees is equally important to the successful implementation of a compliance program and the reduction of any potential for fraud and abuse. In addition to serving as a contact point for reporting problems, the compliance officer should be viewed as someone to whom personnel can go to get clarification on the facility’s policies. Questions and responses should be documented and dated and, if appropriate, shared with other staff so that standards can be updated and improved to reflect any necessary changes or clarifications.⁹⁵

2. Hotlines and Other Forms of Communication

The OIG encourages the use of hotlines, ⁹⁶ e-mails, newsletters, suggestion boxes, and other forms of information exchange to maintain open lines of communication. ⁹⁷ If the nursing facility establishes a hotline, the telephone number should be made readily available to all employees, independent contractors, residents, and family members by circulating the number on wallet cards or conspicuously posting the telephone number in common work areas. Nursing facilities also are required to post the names, addresses and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, State licensure office, State ombudsman program, the protection and advocacy network, and the State Medicaid Fraud Control Unit.⁹⁸

Employees should be permitted to report matters on an anonymous basis. Matters reported through the hotline or other communication sources that suggest substantial violations of compliance policies or Federal health care program statutes and regulations should be documented and investigated promptly to determine their veracity. The compliance officer should maintain a log that records such calls, including the nature of any investigation and its results.⁹⁹ Such information, redacted of individual identifiers, should be included in reports to the governing body, the CEO, and compliance committee.¹⁰⁰ While the nursing facility should always strive to maintain the confidentiality of an employee’s identity, it also should make clear 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. However, the OIG believes all facility employees, when seeking answers to questions or reporting potential instances of fraud and abuse, should know to whom to turn for attention and should be able to do so without fear of retribution.

Summary
Background
I. Introduction
II. Compliance Program Elements
   A. The Seven Basic Compliance Elements
   B. Written Policies and Procedures
   C. Designation of a Compliance Officer and a Compliance Committee
   D. Conducting Effective Training and Education
   E. Developing Effective Lines of Communication
   F. Auditing and Monitoring
   G. Enforcing Standards Through Well-Publicized Disciplinary Guidelines
   H. Responding to Detected Offenses and Developing Corrective Action Initiatives
III. Assessing the Effectiveness of a Compliance Program
IV. Conclusion
Appendix