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 Phase 3 Main Elements

Compared with the sheer volume of content, mandates, and changes in Phases 1 and 2 of the Requirements of Participation, Phase 3 involves a fairly short list. Among the highlights:
  • All long term care facilities must develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on care systems, outcomes, and quality of life.
  • Providers must have created the facility-based assessment designated in Phase 2 and must create systems to track, report, identify, and prevent adverse events; obtain feedback from staff, residents, and families; and collect data from all departments, including the establishment and monitoring of performance indicators.
  • Facilities are required to assess patients and provide “trauma-informed care,” that is, the necessary behavioral health services in accordance with the patient’s plan of care. The assessment requires facilities to determine direct care needs. Staff are required to have appropriate competencies and skills to provide behavioral health care and services, including mental and psychological illnesses.
  • Facilities are required to have a system in place for infections and communicable diseases prevention, identification, reporting, investigation, and control not just for residents, but also for staff, volunteers, visitors, and others. As part of this effort, facilities must have a designated infection prevention and control officer who has specialized training in and for whom infection prevention and control is a key responsibility. This person must serve as a member of the quality assessment and assurance committee. Facilities also must have a surveillance system.
  • Phase 3 requires the operating organization for each facility to have a compliance and ethics program that has written compliance and ethics standards, policies, and procedures to reduce the prospect of criminal, civil, and administrative violations.
  • Facilities are required to have a call system from each resident’s bedside and bedrooms that accommodate no more than two residents. Each resident room must be equipped with a bathroom that has—at least—a toilet, sink, and shower. Additionally, facilities must establish policies that align with applicable federal, state, and local laws and regulations regarding smoking, including tobacco cessation, smoking areas, and safety.
  • Facilities must develop, implement, and maintain training programs for new and existing staff, others providing services under contractual arrangements, and volunteers, consistent with their roles and responsibilities. Training topics must include communication, resident rights and responsibilities, QAPI and infection control, abuse and neglect, exploitation, compliance and ethics, and behavioral health, as well as in-service and other training for nurse assistants.
The RoPs include several dietary requirements addressing staffing, dietitian qualifications, menus and nutritional adequacy, provision of food and drink, frequency of meals, ordering therapeutic diets, use of feeding assistants, and food safety.

Person-centered care underpins everything. For instance, there is a greater emphasis on involving residents in care planning and ensuring that it includes their individual goals. This is intended to keep the plan focused where it needs to be focused. “Remember to involve everyone, including frontline staff who know the resident best, and work together to achieve the resident’s goals,” AHCA’s Sara Rudow says.

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