Published on June 21st, 2023

Compliance and ethics programs are crucial for healthcare organizations to ensure they are following the necessary laws and regulations. One such regulation is §483.85, which requires each facility to have a compliance and ethics program in place. In this blog, we will discuss the required components of such a program and how SMK Medical can help organizations ensure they are in compliance and not cited for F Tag 946.

Required Components of a Compliance and Ethics Program

The first required component of a compliance and ethics program is establishing written standards, policies, and procedures. This ensures that everyone within the organization knows what is expected of them and what actions are required to ensure compliance. Additionally, high-level personnel should be assigned to oversee the program and ensure that it is being followed properly.

The second required component is sufficient resources and authority for these individuals. This ensures that those overseeing the compliance and ethics program have the necessary tools and authority to make necessary changes and ensure compliance. Due diligence should also be exercised to prevent delegation to individuals with a propensity for criminal, civil, and administrative violations.

Effective communication and mandatory training are also required components of a compliance and ethics program. Everyone within the organization should be made aware of the program and trained on the necessary policies and procedures to ensure compliance. Reasonable steps, such as monitoring and auditing systems, should also be taken to achieve compliance.

Consistent enforcement and appropriate response to correct and prevent future occurrences are the final required components of a compliance and ethics program. This ensures that everyone within the organization is held accountable for their actions and that appropriate measures are taken to correct any violations.

SMK Medical Can Help Ensure Compliance

SMK Medical is a healthcare consulting firm that can audit an organization's policies and procedures to ensure compliance with §483.85 and F Tag 946. By doing so, organizations can avoid being cited by CMS and ensure they are following the necessary laws and regulations.

3 Actionable Items to become compliant

If an organization wants to ensure they are in compliance with §483.85 and F Tag 946, there are several actionable items that administrators can take:

Review and update existing policies and procedures to ensure they are in line with the required components of a compliance and ethics program. This includes establishing written standards, assigning high-level personnel, and ensuring effective communication and mandatory training.

Assign a designated compliance officer and compliance liaisons at each facility to oversee the program and ensure everyone within the organization knows the policies and procedures.

Implement monitoring and auditing systems to ensure that everyone within the organization follows the necessary policies and procedures and takes the necessary steps to achieve compliance.

By taking these actionable items, organizations can ensure they are in compliance with §483.85 and F Tag 946 and avoid being cited by CMS. Additionally, organizations can ensure they provide their patients with the highest level of care and follow the necessary laws and regulations. Contact SMK Medical today to ensure your organization is in compliance with CMS regulations.

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