Less than five months before the final phase of the Rules of Participation were set to go into effect, CMS has proposed yet another rule that significantly changes some components and delays others for at least a year.

Provider organizations said they are gearing up to help members understand all the nuances in 110-pages of changes. Many providers had already been planning for — and putting spending toward — the goals based on a November 28 deadline, said Steven Littlehale, BSN, Chief Innovation Officer for Zimmet Healthcare Services Group.

That was especially true for the Quality Assurance and Performance Improvement program, which requires every facility to develop and maintain a comprehensive, data-driven plan to tackle patient care outcomes.

The original QAPI standards set specific parameters for design, scope and feedback that would now be removed to give providers more flexibility. But the ship has sailed for many, Littlehale said.

“It is July. The idea that these significant initiatives haven’t been already contemplated for a fall 2019 start date is naïve,” said Littlehale, Chief Clinical Officer, Emeritus for PointRight. “Most providers I speak with have QAPI implemented for quite some time. It’s more the fear, and associated resources required, of regulatory penalty that was causing stress. As we know, surveyor interpretation of the regulations is the real … care here.”

In the proposed rule, posted to the Federal Register Tuesday evening, CMS recommends having surveyors look at QAPI plans at the end of an inspection. That could limit the possibility that areas identified for improvement would be used as “gotcha” items.

Providers may adjust their current QAPI approaches should the proposed rule become final, said Janine Finck-Boyle, Vice President of Regulatory Affairs for LeadingAge.

“This is an opportunity for our members,” she told McKnight’s. “Rather than being required to follow strict, overly prescriptive directives on how to comply with, for example, QAPI or compliance and ethics, the proposed rule allows members some flexibility to craft programs that leverage their facilities’ unique strengths and resources with the goal of achieving full compliance and providing quality care that meets the unique needs of their communities – that is, residents, families and staff.”

CMS also clarified Tuesday that some QAPI data could be used to complete a new facility assessment requirement, while data gathered for the assessment could feed into QAPI planning and monitoring efforts.

Filling the roles correctly

Several experts noted the importance of understanding which sections of Phase 3 will be delayed — mostly those related to QAPI and compliance — and which have changed.

Trauma-informed care and staff competency requirements, for instance, remain unchanged and are expected to be enforced by Nov. 28, 2019.

Qualifications for some new positions, including infection preventionists and compliance appointees, would be relaxed under the new rule. But CMS still expects that each facility will have required roles filled when the rest of Phase 3 kicks in on Thanksgiving Day.

The Infection Preventionist, whose responsibilities include overseeing facility-wide infection control protocols and antibiotic stewardship, would no longer need to be at least “part time.” That opens up the possibility that consultants or nurses could assume the role as long as they spend “sufficient time” at the facility.

In addition, CMS has proposed grandfathering in food and nutrition directors who didn’t meet earlier proposed requirements. This revision allows experience and “frequently scheduled consultations” from a qualified dietitian to meet the requirement.

In another move cheered by providers, CMS also removed many of the requirements for compliance, including the appointment of a compliance officer and compliance liaisons. Providers may also review the compliance program they create biennially rather than annually under the new proposal. There also will no longer be a requirement to have a “compliance and ethics program contact person” to receive reports of suspected violations.

“If the proposed rule becomes final, these specific titles may not be required but a compliance and ethics program will still be required as is a high-level person of the operating organization to oversee the overall program,” said Amy Stewart, RN, Vice President of Curriculum Development for the American Association of Post-Acute Care Nursing. “Potential violations still require reporting. Facility leaders need to consider who will take on this task.”

CMS has said that all of its proposed changes are intended to improve regulations; streamline procedural solutions for businesses entering and operating in the healthcare marketplace; and reduce costs and other burdens.

The agency estimated reducing information collection expectations would save providers about  $59 million annually, while other operations reforms could trigger $210 million in annual savings. When combined with relaxed construction standards, CMS projects cost savings of about $616 million over the rule’s first five years.