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Phase III

What's Yet to Come? Phase III: November 28, 2019

The CMS-phased approach for the rollout, spreading out implementation of the various requirements over three years, ends with the implementation of Phase III on November 28, 2019. The three phases were categorized based on CMS's assessment of each revision's complexity and the extent to which interpretive guidance and survey processes will need to be revised.

Phase III has requirements that need more time to implement (personnel hiring and training, implementation of systems, approaches to quality), so it was set for three years after November 28, 2016 and requires all areas from Phases I and II to be compliant.

Proposed Phase III Areas of Compliance

§483.85 Compliance and Ethics/Ethics Committee/Facility Compliance & Ethics Designee
§483.21 Comprehensive Person - Centered Care Planning/Trauma informed care
§483.40 Behavioral Health Services/Residents with history of trauma/PTSD
§483.75 QAPI - Quality Assurance and Performance Improvement/Full Implementation of QAPI and integration of Infection Preventionist
§483.90 Physical Environment/Resident call light next to the bed
§483.95 Training Requirements/Training requirements for all staff, contractors, volunteers

A Work in Progress: Preparing for Phase III Implementation

§483.85(c)(1) Compliance and Ethics
The operating organization for each facility must develop, implement, and maintain an effective compliance and ethics program that contains, among other elements, established written compliance and ethics standards, policies, and procedures to follow that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under the Act and promote quality of care, which include, but are not limited to

  • The designation of an appropriate compliance and ethics program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution; and
  • Disciplinary standards that set out the consequences for committing violations for the operating organization’s entire staff; individuals providing services under a contractual arrangement; and volunteers, consistent with the volunteers’ expected roles.

§483.75(c) QAPI feedback, data collection, and monitoring
Facility must establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse events monitoring. The policies and procedures must include, at a minimum, the following:  Facility maintenance of systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

  • Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at § 483.70(e) and including how such information will be used to develop and monitor performance indicators.
  • Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.
  • Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d)(2) QAPI systematic approach for quality improvement
The facility will develop and implement policies addressing

  • How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
  • How they will develop corrective action that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
  • How the facility will monitor the effectiveness of its performance improvement activities to ensure improvements are sustained.