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CMS Proposes Changes to Delay Some Parts of Phase 3 Requirements of Participation

Posted Aug 5, 20195 min Read

Regulatory & Clinical

The Centers for Medicare & Medicaid (CMS) announced on July 17, 2019, a proposed rule, Medicare & Medicaid Programs: Requirements for Long-Term Care Facilities: Regulatory Provisions to Promote Efficiency and Transparency.

  • First, I would like to stress that the proposal means that all or part of the suggested items are possible but not actual until a final rule is publish by CMS.
  • Providers should continue with action toward compliance with all Phase 3 requirements until a final rule is published.
  • PDPM implementation date of October 1, 2019 has not been delayed.

Regulatory areas that could be affected by the proposal are: Resident Rights, Admission, Transfer, and Discharge Rights, Quality of Care, Nursing Services, Behavioral Health, Pharmacy Services, Food and Nutrition Services, Administration, Quality Assurance and Performance Improvement, Infection Control as it relates to workforce concerns, Compliance and Ethics, Physical Environment.

Residents Rights – Two proposed changes

F-Tag 555 – The Right to Choose & Be Informed of Attending Physician


  • Proposal to remove language stating that a facility must ensure residents “remain informed” about their attending physician.
  • Change: Residents only need to be informed of their primary care physician’s information upon admission, when the information changes and/or upon request.

F-Tag 585 – Grievances


  • Clarify the definition of grievance.  Noting, there is confusion between “resident feedback” and a true grievance related to quality of care.
  • Review and or revise the facility grievance policy to ensure how it determines whether something was a grievance or feedback.
  • Reduce the retention period for grievances from 3 years to 18 months.
  • Remove specific duties required of a designated grievance official. Making it possible to delegate responsibility to more than one person.

Admission, Transfer and Discharge Rights


  • Send a copy of a transfer or discharge notice to the LTC Ombudsman Office only when there is a facility-initiated involuntary transfer or discharge.

Quality of Care


F-Tag 700 – Bed rails

  • Revision to remove references to the “installation” of bed/side rails and only refer to the “use” of bed/side rails.

Nursing Services


F-Tag 732

  • Reduce data retention period from 18 months to 15 months.

Pharmacy Services


  • 483.45
  • Require facility policies, standard, and procedures pertaining to the use of psychotropic medications use recognized standards of practice including circumstances under which PRN orders for psychotropic medications could be extended beyond 14-day limitation while taking into consideration the individual needs.
  • An extension of PRN psychotropic medication, including PRN antipsychotic medication, must, in additions to existing requirements, be in accordance with facility policy.
  • Allow renewal of PRN orders for psychotropic and antipsychotic medications with physician or prescribers rationale in the medical record.

Infection Control


  • 483.80
  • Requirement of the infection preventionist be a part-time employee of the facility to instead be a person who has “sufficient time at the facility to achieve the objective of the regulation”.

Compliance and Ethics Program


  • 483.85
  • Change requirement of an annual review of the Compliance and Ethics program to a periodic review.
  • Remove the requirement of a designated contact person for reporting suspected violations

For originations with 5 or more facilities:

  • Remove requirements for a designated compliance officer, compliance liaison at each facility, and annual training.

Physical Environment


  • 483.90
  • Allow facilities that were Medicare or Medicaid certified before July 5, 2016, that have used the FSES to determine equivalent fire protection levels, to continue to use the 2001 FSES mandatory values when determining compliance for containment, extinguishment and people movement requirements.
  • New resident room requirements would apply to newly constructed facilities and newly- certified facilities that have not been previously a long-term care facility.

Food and Nutrition services


  • 483.60
  • Change requirements for individuals serving as director of food and nutrition services if no qualified dietitian or other clinically qualified nutrition professional is employed full-time. Eliminate current requirements and instead allow nursing homes to designate as director of food and nutrition services an individual who has 2 or more years’ experience in the position or who has completed a course of study in food safety that includes topics such as foodborne illness, sanitation procedures, and food purchasing/receiving.



  • 483.70
  • Change the requirement of an annual review of the facility assessment to a biannual assessment review.

Quality Assurance and Performance Improvement

  • 483.75
  • Simplifies and adds facility flexibility in developing and tailoring a QAPI program.

A call to action from providers:

Be aware that your participation is needed to ensure the proposal results in a final rule.

The proposal rule in now in the comment period until September 16, 2019.  AHCA and IHCA/INCAL will continue to analyze and inform members of the further details of this proposed rule.  IHCA/INCAL encourage our members to submit comments to CMS directly or with our assistance.

Please direct your questions or comments to

About the Author

Lori Davenport