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Richter ShareSource Blog

Understanding the CMS Requirements of Participation Past and Future


Note: This is the first blog in our multi-part blog series on the CMS Requirements of Participation.

AdobeStock_216238626Did you know that one in three long-term post-acute care (LTPAC) residents is harmed by an adverse event within 35 days of their stay? Indeed, it is true, and the statistics from the Office of Inspector General don’t stop there:

  • 59% of events are preventable
  • 37% of such events medication related (medication induced change in mental status, excessive bleeding)
  • 37% are resident related (fall, electrolyte imbalance, pressure injury)
  • 26% are infection related
  • 50% of those residents affected returned to the hospital

This is why the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) is so important and why it reflects advances in theory and practice of service. (Just as quick background, the IMPACT Act requires the reporting of standardized patient assessment data with regard to quality measures and standardized patient assessment data elements (SPADEs).)

There are some major themes that we can see while reading the Centers for Medicare and Medicaid Services (CMS) Requirements of Participation, including:

  • Quality
    • Quality of Life/Quality of Care
    • Special care issues: restraints, pain management, bowel incontinence, dialysis services, trauma informed care
    • Quality Assurance and Performance Improvement (QAPI)
  • Facility Assessment and Competency-Based Approach
    • Accounts for diversity in populations and facilities
    • Focus on each resident achieving highest practicable physical, mental and psychosocial well-being
  • Cross-cutting priorities
    • Reducing unnecessary hospital readmissions
    • Reducing the incidence of health care-acquired infections
    • Improving behavioral health
    • Safeguarding nursing home residents from the use of unnecessary psychotropic (antipsychotic) medications
  • Comprehensive Review and Modernization
    • Reorganized
    • Updated
    • Consistent with current health and safety

Let’s do a quick recap of the items in Phases 1, 2 and 3:

  • Phase 1 (Nov. 28, 2016):
    • Freedom from abuse, neglect and exploitation
    • Admission, transfer and discharge rights
    • Comprehensive person-centered planning
    • Sufficient staffing
    • Drug regimen review
    • Dental care
    • QAPI
    • Smoking
  • Phase 2 (Nov. 28, 2017):
    • Behavioral health services
    • QAPI plan
    • Baseline care plan
    • New survey process
    • Infection control – facility assessment and antibiotic stewardship
    • Compliance and ethics
    • Physical environment – smoking policy
  • Phase 3 (Nov. 28, 2019):
    • QAPI implementation – reporting to the governing body
    • Freedom form abuse and neglect – coordination with QAPI plan
    • Infection Control Preventionist on staff and participating in the QAA meetings
    • Trauma informed care – comprehensive person centered care planning, quality of care and behavioral health
    • Compliance and ethics – all organizations must have a functional compliance and ethics program with written compliance and ethics standards, policies and procedures  
    • Physical environment – call lights at bedside
    • Training requirements specified for all staff, contractors and volunteers. Training must include: effective communication; resident rights; facility responsibilities; dementia management and abuse prevention; freedom from abuse, neglect and exploitation; QAPI; infection prevention; compliance and ethics. Dementia management and resident abuse prevention training is a required component of the 12 hours of annual nursing assistant training
    • Food and nutrition – within five years of the effective date of the final rule, organizations need to hire/contract a dietician and a Director of Food and Nutrition services

If you have not begun preparation for Phase 3, now is the time to start. Phase 3 requires a fair amount of full implementation and integration with QAPI. This is not something you will want to try implementing at the last hour.

Do you have questions about Phase 3 or other clinical challenges? Call Richter’s clinical education consultants at 866-806-0799 to schedule a free consultation.

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