The third phase of the Centers for Medicare & Medicaid Services (CMS) new Requirements of Participation (RoP) for long-term care facilities (LTCs) takes effect this fall. Published in October 2016, the new RoP has been implemented in three phases. The first phase took effect November 28, 2016, and the second a year later. Phase Three—which presents the heaviest lift for facilities—takes effect November 28, 2019.
Thereafter, facilities must maintain full compliance with all new RoPs or risk substantial penalties. Also, given the weight assigned to state survey results in CMS’ Nursing Home Compare, failure to comply with the new RoPs will likely result in a lower star rating.
With the first two phases, state surveyors demand more than “checkbox compliance;” they are closely scrutinizing the effectiveness of facilities’ new processes and practices. With Phase Three, facilities must be ready to show surveyors how they identify, respond to, and mitigate different types of risk. Also, given CMS Administrator Seema Verma’s recent announcement regarding enhanced enforcement activity, it is likely there will be more surveyors in the near future.
To comply with Phase Three, facility leaders must focus on seven specific requirements:
- Quality Assurance & Performance Improvement (QAPI) Program (42 CFR, §§ 483.12, 483.70, 483.75)
- Each facility, including those that are part of a multi-unit chain, must develop; implement; and maintain an effective, comprehensive, data-driven QAPI program focused on indicators, outcomes of care, and quality of life.
- The QAPI program must be involved with the review of allegations and incidences of abuse, neglect, and exploitation, in accordance with § 483.75.
- The governing body is responsible and accountable for the QAPI program, in accordance with § 483.75.
- Person-Centered Care Planning (§ 483.21)
- The services provided or arranged by the facility must be culturally competent and trauma-informed. This is outlined in the resident care plan.
- Trauma-Informed Care/Behavioral Health Services for History of Trauma Post-Traumatic Stress Disorder (PTSD) (§§ 483.25, 483.40)
- The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice, and account for residents’ experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization.
- The facility must have sufficient staff with the appropriate competencies and skill sets to care for residents who have mental and psychosocial disorders, as well as for residents with a history of trauma and/or PTSD, as identified in the facility assessment conducted pursuant to § 483.70. This facility must also implement non-pharmacological interventions.
- Infection Preventionist (§ 483.80)
- The facility must designate at least one individual as the infection preventionist (IP) responsible for its infection prevention and control program.
- The IP must:
- Have primary professional training in nursing, medical technology, microbiology, epidemiology, or a related field.
- Be qualified by education, training, experience, or certification.
- Work at least part-time at the facility.
- Have completed specialized infection prevention and control training.
- Serve as a member of the QAPI program.
- Compliance and Ethics Program (§ 483.85)
- The facility must develop, implement, and maintain a written compliance and ethics standards program. The facility must review the program annually and make any necessary revisions.
- Organizations with five or more facilities also must implement:
- Mandatory annual training about the organization’s compliance and ethics program.
- A designated compliance officer whose major responsibility is the organization’s compliance and ethics program, and who reports directly to the organization’s governing body.
- A designated compliance liaison located at each of the organization’s facilities.
- Physical Environment (§ 483.90)
- The facility must provide residents with the capacity to call for staff assistance at their bedsides.
- Staff Training and Competencies (§ 483.95)
- The facility must develop, implement, and maintain an effective training program for all new and existing staff, contract service staff, and volunteers. Training topics must include, but are not limited to, communication, residents’ rights and facility responsibilities, QAPI, infection control, compliance and ethics, dementia management, resident abuse prevention, care of the cognitively impaired, and behavioral health.
Establishing a culture of compliance requires organizational leadership, adequate resources, and sufficient time to influence widespread change. Facilities must have competent awareness of the state surveyors’ expectations and remain apprised of upcoming regulatory changes.
PYA’s best practices for preparing for and achieving Phase Three compliance include:
- Review the Final Rule and reference the State Operations Manual, Appendix PP.
- Evaluate or develop the compliance program, including all relevant policies and procedures. This will accelerate discernment of the appropriate material to incorporate from Phase Three.
- Implement ongoing staff training programs to increase understanding of these new regulatory requirements. These trainings should stress the critical importance of RoP compliance.
- Call on state and national long-term care associations and professional consultants for support.
PYA’s compliance team offers a robust range of compliance services and has carefully studied the regulatory changes of long-term care facilities RoP since its inception. If you would like more information on how your organization can best prepare for the sweeping changes in Phase Three, or about any matter involving compliance, valuation, or strategy and integration, contact one of our PYA executives below at (800) 270-9629.
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