Kentucky Association of Health Care Facilities
Kentucky Association of Health Care Facilities
Kentucky Center for Assisted Living

Event Details

KAHCF Webinar Moving Mountains Series-Phase 3: Implementing an Effective SNF Compliance & Ethics Program
Tuesday, February 5, 2019 2:30 PM - 3:45 PM


Click to Register

Seminar 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.


2:30 SNF Ethics & Compliance Program Fundamentals

* Purpose/Voluntary Compliance Benefits

2:40 Required Components Phase 3 with Action Planning


* Written Standards

* Oversight, Resources & Authority

* Communication of Standards/Training

* Reasonable Steps to Achieve Compliance

o Auditing & Monitoring

o Reporting Systems

* Disciplinary Standard Enforcement

* Violation Response Plan

* Investigations

* Annual Review

3:30  or More Facility Requirements


3:45 Closing Comments


Learning Objectives

1. Understand the key components of Phase 3 Compliance and Ethics Programs and actions to achieve the requirements.

2. Gain knowledge in the assessment of compliance vulnerabilities for the post-acute provider setting.

3. Identify practical operational and compliance program activities to promote ethical and compliance practice and respond to potential violations.

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


* Shelly Maffia, MSN, MBA, RN, LNHA, QCP, Clinical Consultant

Shelly Maffia is a Registered Nurse and Nursing Home Administrator with over fifteen years of experience serving in long term care leadership and consulting positions, including positions as Director of Nursing, Administrator, and Corporate Nurse Consultant and Training Positions. She earned the QAPI Certified Professional (QCP) credential from the American Association of Nurse Assessment Coordination (AANAC), which was established to promote the highest standards for QAPI program implementation in the long-term care profession.

* Amie Martin, OTR/L, CHC, RAC-CT, Clinical Consultant

Amie Martin is an Occupational Therapist and Compliance Officer with over twenty years

of experience serving in long term care leadership positions and as a clinical program specialist. Amie is

certified in healthcare compliance. She has successfully partnered with providers to develop and implement

Compliance and Ethics Programs, achieve 5-star survey results, and ensure Medicare reimbursement accuracy as Founder and President of Proactive Medical Review Consulting.

* Eleisha Wilkes, RN, RAC-CT

Eleisha Wilkes is a Registered Nurse and AANAC certified MDS consultant with over fifteen years of experience in long term care. She has served as a Director of Nursing, Case Manager and Resident Assessment Coordinator with extensive responsibility and success in driving QA in the areas of person centered assessment and care planning through effective systems, staff development, and interdisciplinary team collaboration. Eleisha specializes in Emergency Preparedness, MDS 3.0, reimbursement compliance, competency based staff education programs, SNF/NF survey readiness, and Phase 1-3 Requirements of Participation compliance.


Member - $55
Non Member - $110

Continuing Education

This seminar has been 6pproved for 1.25 contact hour for nursing facility administrators and nurses by the Kentucky Board of Licensure for Long-Term Care Administrators and Kentucky Board of Nursing for RN/LPNs. KBN 

NAB Approved Contact Hours: 1.25 Each

Cancellation Policy

Cancellations must be made in writing and emailed to or faxed to (502-425-3431). Cancellations by phone will not be accepted. Cancellations received no later than January 29 will receive a full refund. Cancellations received between January 29-Feb 4  will receive a refund of 1/2. Registrants who do not attend or who do not complete the full webinar will not receive a refund unless prior written notice is given to the KAHCF office.