LeadingAge New York Adviser Adviser LeadingAge NewYork Spring 2019 final | Page 28

An Overview of the Requirements of
Participation Phase 3
LeadingAge New York ProCare’s Mary Wassel and Elliott Frost spoke of the upcoming third phase of the
nursing facility Requirements of Participation (RoP) that will take effect Nov. 28, 2019. The presentation was
a high-level discussion about the RoP Phase 3 and highlighted key changes to provide an overview of the
programmatic and systematic revisions that require training of staff.
Trauma-informed care is a significant addition under the new requirements. Under F659, the services
provided by the facility, as outlined by the comprehensive care plan, must be culturally competent and
trauma-informed. The facility must ensure that services provided are delivered by individuals who
have the skills, experience and knowledge to do a particular task. F699 details Trauma-Informed
Care, namely that the facility must ensure that residents who are trauma survivors receive
culturally competent, trauma-informed care in accordance with professional standards
of practice and accounting for residents’ experiences and preferences in order to
eliminate or mitigate triggers that may cause re-traumatization.
Behavioral health is another focus. The intent of F741, Competencies, is to ensure
that the facility has sufficient staff members who possess the basic competencies
and skill sets to meet the behavioral health needs of residents for whom the facility has
assessed and developed care plans. The facility must consider the acuity of the population
and its assessment.
Additions to the Quality Assurance and Performance Improvement (QAPI) oversight regulation
are also noteworthy. Although the QAPI/Quality Assessment and Assurance (QAA) improvement plan
was implemented in Phase 1, Phase 3 requires facilities to develop and implement written policies and
procedures that establish coordination with the QAPI program to monitor and review incidents (trends,
patterns, etc.) indicating abuse, neglect, misappropriation and exploitation.
Another revision to the QAPI regulation is that the governing body is responsible and accountable for the
QAPI program (F837). This regulation is intended to ensure that the facility has an active, engaged and
involved governing body that is responsible for establishing and implementing policies regarding the
management of the facility. Moreover, the governing body and/or the executive leadership team
will have to adopt policies and practices to document that they are meeting this oversight
requirement. The requirements under F865 are intended to ensure that facilities develop a
plan that describes the process for conducting QAPI/QAA activities, such as identifying and
correcting quality deficiencies as well as opportunities for improvement, which will lead
to improvement in the lives of nursing home residents, through continuous attention
to quality of care, quality of life and resident safety.
Another significant addition is the inclusion of Infection Preventionist requirements.
The facility must designate one or more individuals as the Infection Preventionist, who is
responsible for the facility’s Infection Prevention and Control Program (IPCP). Further, this
role must be included on the QAA committee.
Compliance and Ethics (F895) is another new regulation. The facility must establish written
compliance and ethics standards policies and must include individuals who have substantial control
over the operating organization or who have a substantial role in the making of policy within the operating
organization. There are further requirements for oversight for an organization with five or more entities.
One noted environmental addition is the inclusion of the facility’s Resident Call System. The facility must be
adequately equipped to allow residents to call for staff assistance through a communication system which
relays the call directly to a staff member or centralized staff work area from each resident’s bedside.
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Adviser a publication of LeadingAge New York | Spring 2019