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Quiz: Is your nursing home ready for Phase 3 compliance?

Posted by Margaret Scavotto, JD, CHC on 1/7/20 8:15 AM

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Quiz snip

As of November 28, 2019, nursing homes are expected to be in compliance with the Phase 3 compliance regulations.

On November 22, 2019, CMS issued a memorandum with an update on the Phase 3 Requirements of Participation. In this memo, CMS advised:

  • CMS will not release updated Interpretive Guidance and training addressing Phase 3 until the second quarter of 2020. CMS is somewhat limited in its ability to survey until then.
  • But... nursing homes are still expected to comply with Phase 3 by November 28, 2019.

What does this mean?

It means that, right now, nursing homes are required by law to comply  Phase 3, including the Compliance and Ethics Program requirements - and CMS expects nursing homes to be in compliance.

Time will tell if or to what degree state surveyors evaluate nursing home compliance programs - but this CMS memo makes clear that survey review is fair game.

MPA recommends that nursing homes implement Phase 3 compliance relying on available guidance (the regulation, 42 CFR 483.85), and keep an eye out for forthcoming updates and guidance. CMS plans to issue guidance in second quarter 2020. In addition, in July 2019, CMS issued a Proposed Rule that would, if made final, modify 42 CFR 483.85, and potentially postpone enforcement. The Proposed Rule has not progressed to a Final Rule yet, which means the proposed changes to Phase 3 Compliance, and the proposed enforcement delay, are not effective at this time. Until that rule is made final, MPA suggests relying on the CMS memo and complying with Phase 3. If and when the CMS Proposed Rule becomes final and an enforcement delay goes into effect, MPA will post an update to the blog.

Finally, remember: regardless of what Phase 3 requires, the OIG is still the gold standard for compliance programs - and OIG expectations should be followed as well.

Has your nursing home met Phase 3 Compliance and Ethics Program requirements?

Take MPA's quiz to find out.

MCS Signature November 2018

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Topics: compliance, Phase 3

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