The long-term care industry is two and a half years into the Mega-Rule process of the consolidated Medicare and Medicaid Requirements of Participation. The third and final phase goes into effect on November 28, 2019.

This gives providers only a few more months to review and understand the requirements and be ready to put the components of Phase 3 into practice. Though some of the requirements are the continuation of several prior phase components, such as QAPI and Antibiotic Stewardship, there are several new requirements as well. Along with getting ready for implementation of Phase 3 of the RoP, facilities also have to understand the new Patient-Driven Payment Model (PDPM) that goes into effect on October first of this year.  Let’s dive into three questions that all LTC leaders should be asking themselves:

Before even thinking about phase 3, are we compliant with the first two phases?

Survey results have been varying, but there have been consistent citation areas where we should remain mindful. In review of several survey results, here are a few examples of the top areas that have been cited and why:

  • Investigate/Prevent/Correct Alleged Violations (F-610): Facilities have been cited for failure to investigate a resident’s allegation of abuse or neglect either timely and fully. 
  • Accident Hazards/Supervision/Devices (F-689): This citation continues to be in the Top 10 for citable areas. This is multifaceted: from not following care plan interventions, to failing to complete a full assessment related of the cause of a fall, to leaving a medication cart open that puts a resident at risk of harm.  
  • Drug Regimen is free of unnecessary drugs (F-757) and Free from Unnecessary Psychotropic Medications and PRN use (F-758): The failure to have a diagnosis for use for an antibiotic, not monitoring side effects of medications. Non-medication interventions were not documented as attempted prior to giving a PRN medication. Medications that go beyond the 14-day PRN rule for Antipsychotic medications or mood-altering medications without physician intervention per regulation for continued use, including Hospice medications.
  • Antibiotic Stewardship Program (F-881): Failure to monitor antibiotic use, failure to log all infections that required antibiotics, failure to identify bacterial organisms, not following criteria for infection determination and failure to include the antibiotic stewardship outcomes in the facility QAPI program. Handwashing is still and issue and is being cited under infection control F-880, as well as facilities missing policy and practice procedures related to legionella and the facilities water system management.

Now that I have Phase 2 under control, what’s next?

Phase 3 requires the following:  

  • QAPI Plans: All subparts, including your process improvement plan (PIP) are due. You must have designed program feedback, data systems and monitoring programs with written QAPI policies to support each of these areas. The facility’s governing body is required to participate and hold the facility accountable for QAPI.
  • Infection Preventionist: This role is required to be a designated active participant on your quality assurance committee. The individual has to have specific qualifications as outlined in the Rules of Participation which includes specialized training in infection control and prevention practices.
  • Trauma-Informed Care: You must ensure that residents who are trauma survivors receive culturally competent trauma informed care that is in accordance with professional standards of practice. This must be a person-centered care plan with interventions that meet the residents’ need to continue to reduce trauma or other traumatic stressors. You must have sufficient staff training and competency in working with these residents.
  • Compliance and Ethics: Written procedures and training of staff to reasonably reduce the prospect of criminal, civil and administrative violations and promote quality of care must be in place.
  • Centralized Call System: A resident call system must be placed by the residents’ bedside that goes directly to a staff member or to a centralized call system.
  • Training Requirements: Continued training for all new and existing staff, contracted staff, and volunteers. Training should include effective communication strategies, resident right training, QAPI, infection control, new compliance and ethics and performance evaluations and competencies.

I understand I need to get this all done, but how?

A facility has to find the time to work towards ongoing compliance practice and keep up with not only the day-to-day running of their individual facility but be on top of all of the compliance Requirements of Participation in order to maintain their operating license. You have some time left prior to November 28th to review, develop, train and implement your policies and procedures for all the areas of Phase 3. Since several new areas such are being introduced, facilities should already be in the process of going through their facility checklists to see how they doing with readiness preparedness.

Facilities need to understand that they are not alone in these processes and that their support systems include trusted advisors whose job is to work towards continual compliance and high-quality resident centered care. Reaching out to a trusted advisor such as a pharmacist, therapist, consultant or state association who has tool kits readily available to help a facility in their compliance success will give a facility the much-needed breathing space and time to get on with what they do best: Taking care of the residents that they serve with the highest quality that they deserve.


Patti Garabaldi is the Director of Clinical Consulting at Consonus Healthcare and an industry expert at developing quality improvement initiatives for companies of all sizes.