How OIG Wants Nursing Facilities To Build Risk‑Based, Competency‑Driven Education

We unpack the OIG’s nursing facility guidance on compliance education and show how to move from generic modules to risk‑based, competency‑driven training that protects residents. We connect risk assessments, CMS alignment, and real‑world methods like Gemba rounds to build proof of learning and safer care.

• annual, data‑driven risk assessment guiding training focus
• tailoring education to resident populations and high‑risk services
• aligning CMS requirements of participation with OIG expectations
• proving competence with skills checks and just‑in‑time coaching
• clear access to compliance officer, committee and safe reporting
• onboarding and validating temporary and contracted staff
• department‑specific and board‑level training needs
• multilingual, culturally aware materials for a diverse workforce
• enforcement, remediation and meaningful incentives for completion

Please feel free to reach out to Verity Consulting at VerityTeam.com if you'd like further assistance with your healthcare compliance needs

Chapters

• 0:00 Host Welcome And Disclaimer
• 0:55 Today’s Focus: OIG Training Guidance
• 2:50 Seven Elements And Risk Assessments
• 4:15 Data‑Driven Education Expectations
• 4:25 2024 Nursing Facility Guidance
• 5:05 Tailoring Training To Resident Populations
• 6:37 Third‑Party Education And CMS Alignment
• 8:02 Competency Over Completion
• 10:06 Role Of Compliance Officer And Committee
• 11:35 Annual And Targeted Training Requirements
• 12:45 Temporary Staff And Timely Onboarding
• 14:24 Formal And Informal Learning Methods
• 15:18 Access To Compliance And Safe Reporting
• 16:45 Gemba Rounds And Just‑In‑Time Teaching
• 18:18 Enforcement And Consequences For Noncompliance
• 19:25 Department‑Specific And Board Training
• 20:35 Contracted Staff Alignment And Verification
• 21:36 Multicultural And Language‑Aware Training
• 22:38 Ventilator Unit Risks And Refreshers
• 23:58 Incentives That Reinforce Competence

Transcript

SPEAKER_00: 0:16

Hello, I will be your host. My name is Deanna Fi. I am a registered nurse and healthcare analyst. Let's get started.

SPEAKER_01: 0:28

The views or opinions expressed in his podcast are for informational purposes only, not intended as legal or professional advice, and may not represent those of Verity Consulting. Although we make strong efforts to make sure our information is current, at the time the podcast episode was recorded, Verity Consulting cannot guarantee that all information in this podcast is always complete. All information in this podcast is subject to change without further notice.

SPEAKER_00: 0:55

Welcome to Vital Compliance Insights. I am your host, Deanna Fe. Today, this episode will focus on OIG, Office of Inspector General, Industry Specific Education and Training Program, Proming for the Nursing Facilities. And this would be within my wheelhouse. So I'm excited to talk about this one. And really I can deep dive into some of these particular areas, but what I'll do is just kind of give you an overview of some of the areas that I want to touch upon today. First of all, I'll just go over the background for the OIG. How did we get here today with our most recent industry-specific guidance? I will focus on the fact that nursing facilities must do robust risk assessments to determine how best to develop a structured educational program focused on relevant training, whether that be formal or informal. I certainly will just review the OIG specific topics that they require to be in the compliance education and training program. And I will always, I'm a nurse by background, I'm a nurse educator by background, so I'll always really want to put focus on assurance of a competency-based and targeted training program to ensure staff are appropriately educated and trained to focus upon resident care safety at all times. And then I'll wrap it up and just touch upon OIG's discussion about incentives for compliance with training and education. So let me just start with really a review of the OIG compliance program education and training history. In 2022, the seven elements were reviewed, and certainly education and training is one of the key components of the seven elements. OIG focused on the fact that the training must be comprehensive and it must be based upon an annual risk assessment. So the facility conducts a risk assessment to determine pathways to take subject matter for key stakeholders. So what are the facilities' risks and who are my stakeholders? And then the education should flow from there. And OIG does speak to providing references, resources that are available for facilities. And certainly they they focus on there must be annual compliance programming training. Okay. Late in 2023. Essentially, OIG revisits some of the things prior in the prior publications, but really again, now they're focusing on facility risk assessments that are data driven. So show me the data. How did you arrive at providing this subject matter education and training based on what data? What was the risk data that was provided that got us here? In November 2024, OIG released the nursing facility industry-specific compliance program guidance. And as far as education and training goes, what I'll focus on here is that the OIG is saying you really need to make sure you look at your population of residents. Again, looking at the risks for the facility. Are you providing education and training tailored to the types of residents, for example, you may have in your facilities? What are those risks in caring for those resident populations? Now I know in my my experiences some facilities will have ventilator types of services provided to their residents, behavioral health services. So are the staff trained in caring for those residents? And are they able to exhibit competency in that care? And OIG recognizes that this isn't the first time nursing facilities have addressed education and training for their resident populations, but they really want to make sure it is bringing in some data-driven information to help focus the facility to provide appropriate and timely education. Now, OIG does recognize there are outside third-party providers that can provide this education. And that's all fine and good, but making sure the elements the OIG is focused upon are included in that education and training. And so just a reminder: CMS, Centers for Medicare and Medicaid Services, does have requirements of participation. And those ROPs, if that's how many of you know them, must align with the OIG requirements as well. So I just wanted to touch upon that. This isn't new information, but just a kind of a refresher. So both CMS, ROP, and OIG, seven elements for facility staff, require that staff have facility staff, and I say staff broadly, they must have knowledge, skills, ability to support the delivery of high quality care. And I'm talking about high quality of care to keep the residents safe, and it's the highest quality of care per the standards of practice. So you're looking at not only providing the education and the training, but there needs to be some evidence of demonstration of competencies. And I really want to focus on that because I can give all kinds of education through the electronic training pathways that we have today. And I can ask you to read modules, do things, but how do I know you know that you have an understanding? So I just wanted to focus on that. This is all found in the OIG's industry-specific nursing facility guidance. And for example, on page 54, you'll find competency-based training is talked about a little bit more in detail there. And I would really recommend you read this if you haven't already. So in a prior episode, I did talk about the importance of a compliance officer and a compliance committee. These folks will be the ones that are key in identifying and helping the facility to conduct risk assessments, meaningful facility-based risk assessments. That will help identify the needed education and training. Okay, now we know there are just standards, uh, let's see, role-based annual training that no matter everybody will have abuse and neglect prevention training. Everyone will. So we know that, but there will be some areas that are picked up on that the compliance officer and the compliance committee will identify some learning needs, and then some training can be tailored to fill in gaps in education, perhaps. And you know, there are various methodologies, depending upon different levels of education for staff, professional, non-professional. You're going to have staff that are temporary employees, contracted employees. And it's really important to make sure the education is timely for those groups of personnel. So we know there will be annual competency-based education and training, okay? It will target compliance, okay, making sure the seven elements are addressed. It needs to be timely for temporary employees also. Now, it's generally understood that before someone, a temporary employee comes to a facility to work, that they've had the education provided on compliance program requirements. But I it's the onus is on the facility to make sure that there's an engagement with the temporary staff agency to make sure that you know what the core educational elements are and that it's in alignment with this nursing facility's goals and requirements. Okay, so based on the fact that OIG's made it very clear that there needs to be a review of the seven elements. Okay. This must be a risk-based assessment to determine the needs for education and training in a facility. It must be comprehensive. The plan must be comprehensive. Now, again, it can be formal and informal training methods. And the OIG talks in the industry-specific guidance on page 49 about different kinds of ideas. And we know today in this age and in 2025, almost 2026, this is an electronic world. And our different age groups are a little more savvy at it than others. But really, it is a whole new world. And AI is a whole nother feature that's coming into play here to hopefully make it a little bit easier for people to learn and understand and demonstrate competency in their compliance education program requirements. Now, the OIG does want addressed the specific topics such as, and this is on page 47 of the industry-specific program guidance, that all groups should know who is the compliance officer. How do I get to that person? Are they accessible and available? Is there a compliance committee? Who are they? How do I get to them? Okay, what do they do actually? The communication needs to be very clear. There needs to be pathways to and from the compliance officer and compliance committee. And there needs to be some clearly established methods where I can reach out, certainly anonymously for fear of retaliation, perhaps, but I want to be able to certainly have a comfort level and go into the compliance officer and say, hey, I have a question. Is this compliant or not? But there are instances we are not naive that some individuals may not be comfortable, may fear for their job, or have, you know, just some confusion about what's okay to talk about or not. And hopefully there is an open door, a very open approach for staff to come forward, disclose concerns. They may not be concerns, but to feel comfortable and share things or ask questions to gain learning and understanding. So I can't focus enough on that. Compliance officer, compliance committee, being accessible, available, approachable, give me different pathways that I can do that. Okay. That is really critical, I believe, in a compliance program. How can I know what my risks are? How can I know where our vulnerabilities are if people aren't comfortable coming forward and bringing up those issues? Okay. How can I develop targeted education? Because maybe I thought I did a good job at providing education on whatever the topic might be, but getting some feedback from staff is saying, really, we we don't really get it, we don't really know. Or people aren't really doing what you thought they were doing. So, all right. Communication pathways must be open and clear. And I'll get to some of that here in a little more. Well, actually, no, let me talk about it now. I've had some great experiences where I've worked with some compliance officers that did an outstanding job at getting out among staff, and that's highly recommended. I think it's actually essential. You know, can't be in an office off, you know, unavailable, out walking around, forming relationships with staff and contractors, volunteers, everybody. They know you, you know them to the extent that's possible. And what I like about the walking around is you can see things with your own eyes, okay? And with your open eyes, you can identify oh, people do understand what's what's supposed to occur in this facility. They do understand the requirements, okay? And I did have a great opportunity several years ago where I was observing a compliance officer and um members of the leadership team doing what were called Gemba rounds, and Gemba that is G-E-M-B-A. And it's um it it the the meaning of that is real place. And it has to do with going out to where the rubber hits a road. I hate to use that expression, but getting out, walking around, being among staff, residents, families, and saying, hey, this is what I see, how's it going? Is is is what we're asking you to do working, not working. And I like that because I could observe positive engagement, and everybody knew what their role was, they knew what they were supposed to do. And if I identified you were a little unsure, we could uh do like just-in-time training and say, oh, wait a minute, you might have forgot this step or you you may have overlooked something. And this is a great teachable moment. So uh just an example, Gamba rounds. Not everybody does that, but if you don't know about it, it's something to look into. There are other methodologies as well, but that's just one example there that I saw that was implemented to help ensure compliance programming initiatives were in place, and certainly to ensure resident quality of care and safety was in place. Now, let's say the compliance officer compliance committee identifies that, well, people really aren't doing what they were supposed to be doing or asked to do and agreed to do. Well, there needs to be some enforcement of noncompliance with the education and training requirements. And I have really observed this on many occasions where, you know, the education department is pulling their hair out, trying to get staff to read emails, uh, participate in training electronically or in the classroom setting, whatever it might be. And it is, there are challenges, but with that, there needs to be consequences. I mean, this needs to be a condition of employment. Okay. I know, as a, for example, a registered nurse, I must, I must participate in abuse prevention training annually. That's just a requirement of my professional licensure, my organization, and there's consequences. If you don't have it done by said date, then you just you don't work. So we understand there are those instances, but hopefully with that, there are very clear written policies and procedures that say, if this, then this, because you know, running a nursing facility, there are so many day-to-day challenges, and we want to make sure everyone comes prepared to provide the highest level of care, safe resident care, and ensure compliance with the compliance committee program requirements. Now, we do know targeted training needs to happen sometimes for certain departments, certain areas where there could be higher risk than others. Oh, let's say billing, the billing department. They're going to have some unique and targeted training for that department. We do know board members need to have compliance education and training. And it's not just a one size fits all. There are different board members, rather, board members with different backgrounds. So not everybody is maybe a healthcare person that is on the board. So the compliance officer and compliance committee need to know who is on the board, what's your background, what's your level of knowledge and education, and they need to be brought up to speed, so to speak. Okay? And I I could get into this one in a lot more detail, but I'll just simply say I mean, this is the advent of, you know, healthcare staffing shortages. I mean, this is not new. It's it's been around since I've been a nurse for 40 years. So we know temporary staff, contracted staff are in facilities. If you're a facility that doesn't have that, uh, you're very fortunate in many aspects. Your residents are very fortunate, and are so are your families. But we know temporary staffing, contracted staff are going to be coming in, and it's important to make sure that their education is in alignment with the nursing facilities, educational programming requirements in the compliance program, but in all the standards of care. Okay. So that's really an important thing. I want to focus on, make sure it's timely. And if I were in charge of the contracting, if you will, then I would want to make sure that I know what those facility staff are being trained on. It is in alignment with my organization. And it's completely appropriate to ask. I'd like to see what you're training and educating your staff on. Can I see did Deanna receive her education before she came here? Okay. What did it include? That is certainly very appropriate to do. We know there are third-party vendors that can provide this, provide packages for education, for in-house staff, but also, you know, other professional groups, contracted providers, and et cetera. Now, all of this being said, this educational programming needs to be targeted to multicultural healthcare staff workers. Okay. There are various languages, and there are many other kinds of things that we need to consider. So how do who are my key stakeholders? What is their background? How can I reach them? How can I make sure I know they are under they're understanding what I'm teaching them? Can they give that back to me? So your educational programming needs to be comprehensive, formal, and informal pathways. Okay. And I know as a nurse, I've had formal education my whole career, but sometimes those informal huddles, whatever they might be called today, those gemba rounds, they are very valuable reminders, refreshers on, okay, what are we trying to do here? Okay, remember, we have a we're running a ventilator unit. We have residents that are here receiving ventilator care, tracheostomy care. Is everybody on board? Do we all know what we're doing? Uh we identified some risks associated with this and thus. Is everybody on board? Does anybody have any questions? So I really find that this is a very dynamic topic, and I could really continue going down the road on this one, but I'll try to wrap it up and just really say the OIG recognizes that there needs to be incentives to train and educate folks. You know, that's where we are in this day and age. Certainly there are consequences. You were hired to meet the minimum requirements, and that includes this and this and this. Now we know there are times when people do have some real challenges. Certainly incentives are very important to people, and it is a sense of reward. So the OIG does recognize that as a reality too, to help people get to the table to learn and to demonstrate competency in compliance programming and in their role requirements. So, with that, if you have any questions about anything that Verity Team Comp Verity Team can provide in consultation, please reach out. And I hope this episode was helpful, a helpful refresher. Thank you for listening. Thank you for listening. Your time is appreciated. We hope you enjoyed this episode of Vital Compliance Insights and found this to be informative. Please feel free to reach out to Verity Consulting at VerityTeam.com if you'd like further assistance with your healthcare compliance needs. Stay tuned for the next episode.