If you are feeling overwhelmed, I completely understand, but the good news is that the implementation of these Requirements is in three phases. The first of course went into effect November 28, 2016, but Phase II and III you have a little more time. Phase II goes into effect on November 28, 2017 but Phase III not until November 28, 2019.
Goals of the SNF Requirements
Let’s start by taking a minute to remind ourselves what the three primary goals are of these new Requirements:
- Person-centered care
- Protecting resident rights
- Improving quality and safety of our residents
You will notice as you read through the Requirements that our obligations to “inform” or “provide” information to our residents has definitely increased. So, as you start working your way through the Requirements always put the resident squarely centered in the middle of your processes. (Not that you don’t already)
A Compliance Perspective
So, let’s talk about some ways to get started and highlight some important areas in the Requirements and from the Compliance perspective:
First and foremost, if you haven’t already done so, you need to identify an inter-disciplinary team to work on this “project”. This is definitely not an “administration” can do it or “corporate” can do it and I will just implement what they tell me to do. These new Requirements need input and execution by your whole team, especially at the Center level.
Now that you have your team together, the first assignment should be read the Requirements. When you first look at the Federal Register and the small print, three column format it seems awfully dense and a bit scary. But keep in mind that most of the pages are the comments and responses to comments related to the proposed changes. These are important to give you a better perspective of what the authors were thinking but the actual new Requirements are only 25 pages. Still plenty to read and digest but not quite so overwhelming.
You can also find a variety of summaries provided by your State Associations and definitely the American Health Care Association (AHCA) and LeadingAge have a ton of resources available to you. Don’t forget to check out the ProviderTrust blogs, webinars and new compliance consulting services too for helpful information.
Let’s take a look at some of the highlights in each of the phases from a Compliance Perspective:
Phase I Highlights:
Phase I implementation is already behind us but I wanted to highlight a couple of areas just to make sure you noticed them and have new processes in place to address:
- New definitions have been added or modified
- New Requirement to notify the State Long-Term Care Ombudsman of ALL transfers and discharges. (Lots of confusion on this one coming from the local Ombudsmen but be careful to follow the rule as written unless you have something in writing from the State Ombudsmen telling you otherwise that you can share with your surveyors)
- Enhanced Grievance process including designation of a Grievance Official
- Join us for our March webinar and receive a breakdown of the Grievance Program Requirements and ways to get started implementing.
- New Requirement related to hiring certain individuals.
- Facility must not employ or otherwise engage individuals who have a disciplinary action against his or her professional license by a state licensure body resulting from abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (Please see my blog dated, March 7, 2017, where we discuss this Requirement in more detail)
Phase II Highlights:
- Clinical P&Ps – There are a number of Requirements that will require clinical policy and procedure updates that as a Compliance Officer you may monitor completion but likely will not have content input.
- Facility Assessment – In my opinion, this is the biggest Requirement in Phase II.
- Requires a review of your physical plant, equipment, contractors, etc.
- Requires a review of all of your staff both in numbers and qualifications/competencies
- Requires a review of the acuity and specialty needs of your residents
- Please watch for a separate blog later this month related to the Facility Assessment
Phase III Highlights:
- Compliance and Ethics Program
- Additional Training Requirements
- Additional QAPI Requirements
- Many of the QAPI Requirements are being implemented in Phase I and I but they all come together In Phase III.
That is just a quick overview of some of the highlights in the new Requirements of Participation to pay close attention to from a compliance perspective. Join our March webinar and get some tips on addressing some of the Phase II and Phase III requirements and some handy resource materials.
As always, we are here to help Compliance Officer’s sleep better at night.
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Written by Donna Thiel
Director, Compliance Integrity | firstname.lastname@example.org
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.