Requirements of Participation: Phase 3 is on the Horizon
Andy Kramer, MD
10/1/2018
By the time this column is published, there will be a little over a year before phase 3 of the Final Rule becomes effective. That day is fast approaching. While studying those regulations, one may try to summarize the main concepts and requirements, and that summary follows. Many organizations have covered most, if not all, of the requirements, while other centers are earlier in implementing programs. And hats off to them. The author of this column hopes that there’s something in the summary that helps most Provider readers and encourages the sharing of program success strategies between centers.
Phase 3 of the new rule touches on multiple issues and care processes, and the regulations require new systems, personnel, and/or training. Prior regulations address many of these same areas, but phase 3 requirements are often more extensive. A major emphasis is training and competency, focusing on specific areas in addition to needs identified in the facility assessment. Nurse assistant training is emphasized, including dementia management, care for residents with cognitive impairments, and abuse prevention.
These four regulatory areas require a program or system with multiple components, often with specific requirements:
■ Infection Prevention and Control, where the requirements involve policies and procedures, program oversight, a designated infection preventionist, process and outcome surveillance, education and training, and antibiotic monitoring to ensure appropriate antibiotic use.
■ Quality Assurance and Performance Improvement builds on the QAPI plan from phase 2 and the five elements of QAPI, leading to more detailed program requirements. The scope of the QAPI program must address all systems of care and reflect the unique care and services that the facility provides.
Written policies and procedures must be implemented for maintaining an effective system to obtain and use feedback; collect and use data, including from the facility assessment; monitor performance; and monitor and investigate adverse events.
After taking actions for performance improvement, facilities are expected to measure success and ensure that improvements are sustained. Priorities for performance improvement activities should focus on high-risk, high-volume, or problem-prone areas.
■ The Compliance and Ethics Program must be designed to prevent and detect criminal, civil, and administrative violations. Components of the program include written standards, policies, and procedures; involvement of specific high-level personnel from the operating organization; sufficient designated resources to ensure compliance; communication of standards, policies, and procedures to staff; consistent enforcement within the organization; and strategies for preventing further violations.
Multifacility organizations have further requirements, including a compliance officer.
■ For Behavioral Health Services, while not a program per se, an organization-wide effort is required to
ensure that residents with mental or psychosocial disorders, as well as those with trauma or post-traumatic stress, are identified in the facility assessment and receive the appropriate care and services. This includes a psychological or psychiatric evaluation, behavioral health treatment plans and monitoring of distress, and accommodations as necessary to reduce distress with emphasis on reducing triggers in the case of trauma-informed care.