Breaking Compliance News Blog

Phase III: Do SNFs need to conduct a compliance program annual review?

Posted by Margaret Scavotto, JD, CHC on 1/21/20 8:00 AM

In a word: yes.

In July 2019, CMS published a proposed rule that would modify the Compliance and Ethics program aspects of the Phase III Long-Term Care Facilities Requirements for Participation.

One of the proposed modifications brought a sigh of relief from the nursing home industry: CMS wants to drop the requirement that nursing homes conduct an annual review of their compliance programs.

Instead, CMS proposes the following: “The operating organization for each facility must periodically review and revise its compliance program to identify necessary changes within the organization and its facilities.”

While CMS did not define “periodically” in the proposed rule, CMS refers to a “biennial” review in the proposed rule comments. Hopefully this will be clarified in the final rule.

Keep in mind that the Proposed Rule has not yet been made final, and, as of November 28, 2019, SNFs are expected to comply with the original Phase 3 compliance requirements at 42 CFR 483.85. But, what if the Proposed Rule becomes final?

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Topics: annual review, compliance, Phase 3

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

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

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?

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Topics: compliance, Phase 3

Phase 3 Nursing Home Compliance Update!

Posted by Margaret Scavotto, JD, CHC on 12/4/19 10:58 AM

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 with Phase 3, including the Compliance and Ethics Program requirements - and CMS expects nursing homes to be in compliance.

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Topics: skilled nursing, guidance, compliance, Phase 3

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