Complete Story
06/30/2022
CMS releases Phase 3 Requirements of Participation
Yesterday, the Centers for Medicare & Medicaid Services (CMS) announced surveyor guidance for Phase 3 Requirements of Participation, as well as clarifications and technical corrections for Phase 2 guidance issued in 2017. Phase 3 Requirements of Participation technically went into effect in 2019, just before the emergence of the COVID-19 pandemic. However, the lack of guidance has largely put RoPs 3 implementation on hold since states rely on the guidance for survey processes and procedures. Yesterday’s announcement restarts implementation, with the deadline for states using the new guidance set for October 24, 2022.
The new guidance comes at a time when nursing facilities are struggling to emerge from the devastating impacts of the pandemic, followed closely behind by an acute workforce shortage. LeadingAge President/CEO Katie Sloan issued a statement immediately following yesterday’s announcement, pointing out that while LeadingAge shares the Administration’s reform goals, “…at this time when the sector is finding its footing after years of COVID-induced financial stress and workforce challenges [and] continuing the additional pile-on of regulations will strain already-stretched providers.” Further, Sloan stated: “We all know that staffing goes hand-in-hand with quality care, and our mission-driven members are working valiantly to stay compliant. But we continue to urge the administration to back its words of commitment to ensuring older adults’ access to care with meaningful action and funding.”
CMS’s release also includes:
- Guidance on new arbitration requirements that were effective as of September 16, 2019;
- Guidance to strengthen oversight of nursing home complaints and facility-reported incidents;
- Revised guidance for all Medicare-certified provider/supplier types to improve consistency across state agencies in communications to complainants; and
- Guidance to clarify the “reasonable person” concept and examples across different severity levels.
Training resources for state survey agencies were made available when the announcement was posted, and are available at the following links:
- QSO-22-19-NH (PDF)
- Appendix PP Guidance to Surveyor for Long Term Care Facilities (PDF)
- SOM Chapter 5 - Complaint Procedures (PDF)
- SOM Exhibit 23 - ACTS Required Field (PDF)
- SOM Exhibit 358- Sample Form for Facility Reported Incidents (PDF)
- SOM Exhibit 359- Follow-up Investigation Report (PDF)
- Psychosocial Outcome Severity Guide (PDF)
CMS also released the following fact sheet late yesterday.
LeadingAge Ohio is also preparing education for staff who are working to rapidly get up-to-speed on the requirements ahead of the October effective date. Details of the Phase 3 guidance will be the subject of the next All-Member Call, scheduled to take place on Tuesday, July 19 at 11am. The call is free to members, but registration is required.
Any questions may be sent to Stephanie DeWees at sdewees@leadingageohio.org.