Skilled Nursing: Requirements of Participation (ROP) Phase 3

Skilled Nursing: Requirements of Participation (ROP) Phase 3

Remember these? Those “new requirements” under 42 CFR 483 that went into effect November 28, 2019. The COVID-19 Public Health Emergency (PHE) has captured most of our attention the last two years; however, surveys have resumed, and you will be surveyed on these standards.  Portions of QAPI and the RD qualifications requirements are still waived under the PHE. 

LeadingAge WA is hosting a 3-part series on Trauma Informed Care, starting April 6th. You can register here.  Jodi Eyigor from LeadingAge National will also be doing a session on this at our Annual Conference in June.

  1. 483.12 Freedom from abuse, neglect, and exploitation
    1. (b)(4) Coordination with QAPI Plan
  2. 483.21 Comprehensive person-centered care planning
    1. (b)(3)(iii) Trauma informed care
  1. 483.25 Quality of care
    1. (m) Trauma informed care
  1. 483.40 Behavioral health services
    1. (a)(1) As related to residents with a history of trauma and/or post-traumatic stress disorder
  1. 483.60 Food and nutrition services (Currently waived)
    1. (a)(1)(iv) Dietitians hired or contracted with prior to effective date—Built in implementation date of 5 years following effective date of the final rule.
    2. (a)(2)(i) Director of food & nutrition services designated to serve prior to effective Built in implementation date Deadline of 5 years following the effective date of the final rule.
  1. 483.70 Administration
    1. (d)(3) Governing body responsibility of QAPI program
  1. 483.75 Quality assurance and performance improvement
    (Portions waived-specifically, CMS is modifying §483.75(b)–(d) and (e)(3) to the extent necessary to narrow the scope of the QAPI program to focus on adverse events and infection control. This will help ensure facilities focus on aspects of care delivery most closely associated with COVID-19 during the PHE)
    1. (g)(1) QAA committee the addition of the ICPO (Infection Control Prevention Officer- This is not waived!)
  1. 483.80 Infection control
    1. (b) Infection “preventionist” (IP)
    2. (c) IP participation on QAA committee
  1. 483.85 Compliance and Ethics program
  2. 483.90 Physical environment
    1. (f)(1) Call system from each resident’s bedside
  1. 483.95 Training requirements

I will be reviewing each of these requirements in more depth over the next few weeks, look for emails with RoP 3 Updates as the subject line, however, if you have any questions, please feel free to contact me!

Laura Hofmann, MSN, RN – Director of Clinical and Nursing Facility Regulatory Services
c: 425-231-4804

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March 30, 2022