Part 3: SNF Requirements of Participation – Licensing

Part 3: SNF Requirements of Participation – Licensing

Did you read the new Skilled Nursing Facility Requirements of Participation (ROP) section 483.12 carefully? In a document of nearly 200 pages and three columns of small print, sometimes it is easy to miss an important change. I read the new ROP multiple times and until just a few weeks ago I missed an important new requirement in the Freedom from abuse, neglect and exploitation section. Hopefully, you aren’t like me and you saw this already but just in case I thought I would highlight the change for you and give you some great news about meeting this new requirement.First, let’s start with a review of this new requirement. The requirement I am talking about is found on page 68855 in the Federal Register dated October 4, 2016 and is section 483.12(a)(3)(iii).

Let’s take a look at the new language/requirement:

§ 483.12 Freedom from abuse, neglect, and exploitation.

(a) The facility must –

(3) Not employ or otherwise engage individuals who –

(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

We know the Requirements of Participation already required us not to employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Nor having a finding entered into the State nurse aide registry concerning the same abuse, neglect, exploitation, misappropriation of property, or mistreatment.

Another important piece of information regarding this requirement is that it was part of the Phase I requirements so this additional requirement went into effect on November 28, 2016. So, if you were like me and missed this important requirement, you may be out of compliance with the Requirements of Participation. You need to review your policies and procedures immediately to make sure you have a process in place to review the licenses of your staff.

Earlier I mentioned that I had some great news about this requirement. Well I do. The great news is that we at ProviderTrust have a core product that monitors professional licensing boards in all 50 states for all types of licenses of persons typically employed by skilled nursing centers.

As a former Chief Compliance Officer in a large nursing home chain, I can tell you that the use of the ProviderTrust products helped me sleep at night and allowed me to feel confident that we were meeting the state and federal regulations as they relate to OIG exclusion monitoring, and state license monitoring.

If you need any help reviewing your current practices, bolstering your compliance program or want to talk with us about the ProviderTrust suite of compliance products such as our state license monitoring give us a call at 615.938.7878.

We look forward to helping Compliance Officers sleep better at night.

You may also like:

Part 1: SNF Requirements of Participation
Part 2: SNF Requirements – One Bite at a Time

Written by Donna Thiel

Director, Compliance Integrity |

Donna works with compliance officers across the country to help reduce the stress and anxiety of this very difficult role. She has been in the post-acute healthcare setting for over 30 years. The last 14 years were spent in the legal/compliance area. Prior to her legal/compliance experience she held a variety of positions in the clinical, operations and IT areas as well.

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