Moving Mountains Webinar – Phase 3: Implementing An Effective SNF Compliance and Ethics Program


Course Description

This 1.25 hour webinar will review SNF Compliance and Ethics Program requirements effective with phase 3 of the Requirements of Participation on November 28, 2019. This session will emphasize developing or updating the SNF Compliance and Ethics Program to meet all required phase 3 components per the final rule. Guidance on effective day to day implementation strategies and operating the program will be provided. A program implementation checklist and risk assessment tool will be shared with participants.

Learning Objectives

  • Understand the key components of Phase 3 Compliance and Ethics Programs and actions to achieve the requirements.
  • Gain knowledge in the assessment of compliance vulnerabilities for the post-acute provider setting.
  • Identify practical operational and compliance program activities to promote ethical and compliance practice and respond to potential violations.


  • Shelly Maffia, MSN, MBA, RN, LNHA, QCP, Clinical Consultant
  • Amie Martin, OTR/L, CHC, RAC-CT, Clinical Consultant
  •  Eleisha Wilkes, RN, RAC-CT

Course Content

1:30       SNF Ethics & Compliance Program Fundamentals

Purpose/Voluntary Compliance Benefits

1:40        Required Components Phase 3 with Action Planning


– Written Standards

– Oversight, Resources & Authority

– Communication of Standards/Training

– Reasonable Steps to Achieve Compliance

– Auditing & Monitoring

– Reporting Systems

– Disciplinary Standard Enforcement

– Violation Response Plan

– Investigations

Annual Review

2:30       5 or More Facility Requirements


2:45       Closing Comments

Target Audience:   Director of Nursing, Assistant Director of Nursing, Nurse Managers, Nursing Home Administrators, Nursing staff and leaders, Quality Assurance Director, Medical Records, MDS staff, Therapy staff