06/29/2022

CMS Releases Phase 3 Requirements of Participation

CMS Releases Phase 3 Requirements of Participation

This afternoon, the Centers for Medicare & Medicaid Services (CMS) announced surveyor guidance for Phase 3 Requirements of Participation, as well as clarifications and technical corrections for Phase 2 guidance issued in 2017. The Phase 3 guidance is scheduled to take effect on October 24, and corresponds to the Requirements of Participation that went into effect on November 28, 2019. The release also includes:

• Guidance on new arbitration requirements that were effective as of September 16, 2019; 
• Guidance to strengthen oversight of nursing home complaints and facility-reported incidents;
• Revised guidance for all Medicare-certified provider/supplier types to improve consisitency across state agencies in communications to complainants; and
• Guidance to clarify the “reasonable person” concept and examples across different severity levels.

Training resources for state survey agencies were made available when the announcement was posted, and are available at the following links:

• QSO-22-19-NH (PDF)
• Appendix PP Guidance to Surveyor for Long Term Care Facilities (PDF)
• SOM Chapter 5 - Complaint Procedures (PDF)
• SOM Exhibit 23 - ACTS Required Field (PDF)
• SOM Exhibit 358- Sample Form for Facility Reported Incidents (PDF)
• SOM Exhibit 359- Follow-up Investigation Report (PDF)
• Psychosocial Outcome Severity Guide (PDF)

LeadingAge Ohio is currently reviewing the guidance and will include a more comprehensive summary of the guidance in tomorrow’s edition of The Source. LeadingAge Ohio is also preparing education for staff working to rapidly get up-to-speed on the requirements ahead of the October effective date. Any questions may be sent to Stephanie DeWees at sdewees@leadingageohio.org.