In November 2019, long-term care providers anticipated forthcoming Phase 3 guidance from the Centers for Medicare and Medicaid services (CMS). However, CMS announced prior to its implementation that it would not be releasing the guidance in time for the launch, but rather releasing the guidance the second quarter of 2020. Then COVID-19 came onto the scene and changed the whole trajectory of things to come. Guidance about how to deal with COVID-19 abounded and Phase 3 guidance was placed to the side to address the immediate concerns of this novel virus.

Phase 3 guidance has been released

Fast forward to June 2022, CMS released QSO-22-19-NH with revisions to Phase 2 and 3 requirements to be effective October 24, 2022.  Guidance was added to address the Phase 3 elements that included trauma-informed care, quality assurance and performance improvement (QAPI), compliance and ethics, and training programs.  In addition to these topics, CMS released additional guidance and information in the areas of abuse, resident visitation, facility-initiated transfers and discharges, binding arbitration agreements, infection prevention and control, and submission of data to the payroll-based journal (PBJ) on nurse staffing, to name a few. Information was added, as well, to address the mental health and substance use disorder needs of residents in facilities that serve this population.

CMS revised guidance to clarify the reasonable person concept located in the Psychosocial Outcome Severity Guide.  This guide serves to help surveyors determine the severity of psychosocial outcomes resulting from identified noncompliance at a specific F tag, including how to determine the severity of the outcome when the impact on the resident may not be apparent or documented and is used in conjunction with the current scope and severity grid. According to CMS, the “reasonable person concept refers to a tool to assist the survey team’s assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident’s position.”

Some changes you will see

In anticipation of the October 24 deadline, facilities should be preparing for these changes.  Some considerations to begin working on include:

• Reviewing the updated guidance in Appendix PP and becoming familiar with the expectations of CMS.
• Reviewing the facility assessment to ensure the facility can meet and address the needs of the residents it serves.
• Reviewing and revising policies and procedures to ensure consistency with compliance standards and updated guidance.
• Reviewing and revising trainings related to communication, behavioral health, QAPI, compliance and ethics, resident’s rights, infection control, and other relevant topics based upon the resident population of the facility.
• Communicating with staff, residents, and families the updated guidance as related to topics relevant to them.
• Auditing resident care plans to ensure culturally competent and/or trauma-informed care interventions are in place for applicable residents.
• Auditing practitioner’s orders to ensure that antipsychotic medications have an appropriate diagnosis for the indicated use of the medication.

While this list is not all-inclusive, the goal is to be proactive to identify the needs of the residents, ensure care and services are compliant against the standards, and if not, identifying those areas that could be presented to the QAA committee as part of the QAPI program for improvement.

The Compliance Store can help

The Compliance Store understands the complexities of the work that long-term care is faced with.  From policies and procedures, to tools aimed to ensure compliance with the myriad of regulations long-term care facilities deal with, The Compliance Store can help relieve some of the burden. For more information, contact us online or call us at 877-582-7347.