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  • Maritza Straub

Happy New Year from RegsPro!

As we kick off this brand new year, we are going to get back to sending out updates on things we are noting in the Long Term Care world.  We apologize for getting away from that, but as 2020 starts, we plan to try to send out at least a few emails a month of resources, tidbits, and helpful information.


While CMS had been considering delaying Phase III of the Requirements of Participation, they ended up not delaying anything except Interpretative Guidelines (IG), (which help surveyors understand how to enforce the new regulations). 

Per CMS, they are expecting to post the new IG by the second quarter of 2020, although it is imperative that that LTC communities be in compliance already with the Phase III requirements. 


McKnights wrote a wonderful article about the complex regulations going into effects sans IG.  

https://www.mcknights.com/news/most-complex-rop-phase-goes-live-thursday-but-cms-says-surveyor-guidance-not-expected-for-months/


There are seven requirements that communities must be in compliance with:


1) 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. Physical Environment (§ 483.90) The facility must provide residents with the capacity to call for staff assistance at their bedsides.

7. 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.


So, while CMS has a few months yet to provide everyone with the interpretative guidelines, we must ensure that we are in compliance with the regulations now, just in case a surveyor should decide to look at one of these seven new phase III components. 


Hopefully, they will hold off so we can all ensure that we are in substantial compliance, but just in case, make sure you have already have the phase III regulations in place or in the process.  Hopefully, when the IG get posted, they will not throw anything in that we weren't expecting and we can finally move on from worrying about the new phase coming in the future.  Best of luck as your surveys come along, may you have wonderful surveys and a reprieve from questions about the phase III requirements.  


Have a wonderful beginning to your year, we

are looking forward to being more in contact as this year progresses.  

~ Kaile and Maritza, the RegsPro Team


#RegsPro, #LTCSOM, #ROPPhase3, #ROP, #CMS, #LTC



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