Is Your Facility Ready for ROP 3?  The Proposed Delay of Some Phase 3 Requirements are NOT FINAL

CMS has proposed to delay implementation of some Phase 3 requirements for one year after the effective date of finalization of the rule. The requirements included in the proposed delay are:

  • Elements of the Quality Assurance and Performance Improvement (QAPI) program including program design and scope; program feedback, data systems, and monitoring; program systematic analysis and systematic action; program activities; governance and leadership; quality assessment and assurance; and required QAPI staff training.
  • Compliance and ethics program requirements as well as required compliance and ethics staff training.

CMS has not proposed to delay implementation of the Phase 3 Infection Preventionist requirements nor the Phase 3 requirements for culturally competent and trauma informed care or the requirements for a call system from the residents’ bedsides.

Because this is a proposed rule, the delay itself is also proposed and does not go into effect until CMS issues a final rule. We have been actively communicating with AHCA seeking clarification on how CMS intends to manage implementation of the proposed delay given their stated intent in the proposed rule “to avoid unnecessary work, confusion and burden associated with implementing provisions, which may then change in a final rule shortly thereafter.” Until we know more, members should continue to prepare for Phase 3 implementation this November.