On November 20, 2024, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released the “Nursing Facility ICPG,” an industry-specific compliance program guidance for nursing facilities.
Background
The Nursing Facility ICPG serves as a voluntary, nonbinding tool to assist facilities in reducing risks related to fraud, waste, and abuse, while promoting operational effectiveness and cost-effective and quality care. The guidance also affects stakeholders who interact with nursing facilities, including individual providers, supply companies, pharmacies, and hospitals.
The guidance is designed to be flexible, recognizing that each nursing facility may face unique challenges. It works alongside OIG’s General Compliance Program Guidance (GCPG), released in November 2023, which applies to all healthcare entities. The Nursing Facility ICPG is an update of OIG’s earlier guidance documents for nursing facilities which were released in 2000 and 2008.
Requirements of Participation (ROPs)
The Nursing Facility ICPG is distinct from the Centers for Medicare & Medicaid Services’ Requirements of Participation (ROPs), which are mandatory for nursing facilities to participate in the Medicare and Medicaid programs. While the recommendations and practical considerations in the Nursing Facility ICPG and GCPG could help an entity comply with the Compliance Program ROPs, an independent review and analysis of an entity’s compliance and ethics program would still be required.
Risk Areas
The Nursing Facility ICPG identifies four overarching compliance risk areas:
(1) Quality of care and quality of life;
(2) Medicare and Medicaid billing requirements;
(3) Federal Anti-Kickback Statute; and
(4) Other risk areas including related-party transactions; the physician self-referral law (Stark Law); anti-supplementation, meaning a beneficiary (or anyone else) cannot be charged by the nursing home any amount in addition to what is required to be paid for covered services under Medicare or Medicaid; HIPAA Privacy, Security, and Breach Notification Rules; and civil rights, including a nursing home’s compliance with anti-discrimination laws.
While many of the risk areas and considerations from the older industry-specific documents have been retained, the updated ICPG reflects OIG’s current insights and enforcement priorities.
The guidance also reiterates the importance of implementing compliance and quality programs at the highest corporate levels within nursing facility chains or systems, when applicable. However, OIG recognizes that a “one size fits all” approach is not possible. For example, as recognized in previous guidance, depending on the nursing facility’s circumstances and characteristics, it may be appropriate to adopt some combination of facility-specific compliance liaisons, regional compliance officers, and/or deputy compliance officers responsible for specific areas, such as compliance audits, investigations, training, and policies. While the Nursing Facility ICPG offers a centralized resource for improving compliance and quality, it is not intended to be exhaustive or prescriptive.
Conclusion
Facilities are encouraged to consider the guidance within the context of their specific operations and local requirements and adapt it to their needs. To that end, in implementing the recommendations in the Nursing Facility ICPG, facilities can strengthen their operations, help ensure that residents receive the best possible care, and reduce regulatory risks and associated expenses.
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