Are you almost at the finish line?


The planned November 28, 2019 deadline for completing the last of the Phase 3 requirements for the Mega Rule will be here in a matter of days. However, at this time, the Centers for Medicare & Medicaid Services has not released any interpretative guidance on the requirements and some proposed changes still hang in the balance. Despite the delay and questions swirling about the fate of some parts of Phase 3. It’s a good time to take stock and check how prepared you are to reach the finish line.


What’s required?
Phase 3 addresses 10 areas, including Quality Assurance and Performance Improvement (QAPI) implementation, Infection Control, Compliance and Ethics and Physical Environment. Some of the regulations in these areas have been partially implemented in the previous phases. For example, the rule addressed care planning earlier but in Phase 3, Section §483.21 (Comprehensive Person-Centered Care Planning) requires that care plans are culturally-competent and trauma-informed.

Phase 3 mandates the development and implementation of an effective QAPI program that includes several elements. Section §483.70 (Administration) requires that the responsibility for the QAPI program is included in the obligations of the governing body. Section §483.12 (Freedom from Abuse, Neglect, and Exploitation) also requires that facilities integrate abuse, neglect and exploitation into their QAPI program.


Phase 3 focuses heavily on several employee training and staff competencies. For example, Section §483.40 (Behavioral Health Services) requires the development and implementation of a process to assess staff competencies for caring for residents with a history of trauma and/or post-traumatic stress disorder. Finally, Section §483.95 (Training Requirements) calls for new training to be implemented for staff, contractors and volunteers for topics such as communication, resident’s rights, abuse, neglect, infection control and compliance and ethics.


The last phase also necessitates facilities add some new personnel responsibilities. Section §483.80 (Infection Control) calls for the hiring or the designation of an infection preventionist who is responsible for the Infection Prevention and Control Program. Section §483.85 (Compliance and Ethics Program) requires that a plan be developed for implementing components of a compliance and ethics program as well as putting a schedule in place to annually review and update the program.


We can help
Whether you’re on time or a little behind, The Compliance Store has a wealth of resources to help you meet your requirements and stay on track. From Phase 3 action plans and publications on QAPI program development to information on trauma-informed care and staff training, we can support your needs. Find out how The Compliance Store can help at