Phase 3 Regulations – Ready or Not!- blog Image

Phase 3 Regulations – Ready or Not!

August 12, 2022
August 12, 2022

This blog is taken from a recent HealthStream webinar. The webinar was moderated by HealthStream’s Jaclyn Franklin and featured Kevin Bandur, Solution Executive – Quality Manager, Tracy Cooley, RN, BSN, Senior Success Manager - Quality Manager, Nathan Wilson, Solution Executive – Quality Manager and Jamie Lamphear, Senior Product Manager - Quality Manager.  The panel addressed a variety of questions and issues associated with the Phase 3 regulations and what they mean for facilities.


Ready or Not!

Phase 3 regulations went into effect on November 28, 2019. Compliance with these and all regulations is now required. Moreover, surveyors will begin using Phase 3 guidance to identify non-compliance on October 24, 2022. While initial guidance was somewhat limited, the Center for Medicare and Medicaid Services (CMS) has now issued guidance that surveyors will begin using in October.


Phase 3 Regulations – What are They?

While compliance with all regulations is required, the panel focused on the newest requirements. Phase 3 regulations cover a variety of issues.

  • Freedom from abuse, neglect and exploitation: this requires facilities to develop policies and procedures that define how staff respond to these issues. The policy must be integrated into their Quality Assurance and Performance Improvement (QAPI) program. Under Phase 3 regulations, the QAPI leader and committee become more integral to the identification of and remedies for these issues. Wilson shared that the new requirement will mean more measurement to insure that facilities are tracking and trending abuse information in order to identify patterns of abuse that may contain clues to the root cause(s) of the problem.
  • Comprehensive Person-Centered Care Planning: Cooley shared that in order to be in compliance with this part of the regulation, the services that a resident receives must be culturally-competent and trauma-informed. Cooley encouraged facilities to begin with an assessment that includes an evaluation of cultural and/or ethnic preferences and the identification of any past trauma. The evaluations should include interviews with residents and family members to ensure that all issues have been identified. “Through your assessment, you should be able to describe the resident’s care requirements that will address culture, ethnicity, religious factors and trauma-related issues,” said Cooley.
  • Governing Body: Each facility must establish a governing body. Bandur shared that this body will be responsible for establishing and implementing policies in addition to the management of the facility. The governing body will also be responsible for the implementation and execution of a strong, data-driven QAPI program. Wilson also encouraged facilities to incorporate clinical areas, quality of life initiatives, and resident choices into the QAPI program to ensure compliance and efficacy of the plan. He also advised facilities to be sure that they were systematically analyzing data to ensure that issues were fully identified and that appropriate interventions were planned.
  • Infection Preventionist: Cooley shared that the person or persons who are serving as the infection preventionist should be trained in nursing, medical technology, microbiology, epidemiology or another related field. She also shared that they must remain current on infection control issues and practices at national, state and local levels.
  • Compliance and Ethics Program: Phase 3 regulations require that facilities have a compliance and ethics program. The goal of the program is to detect and prevent criminal, civil and administrative violations and to promote quality care. “The program must have internal controls to monitor adherence to the statutes, regulations and requirements – which is why strong facility assessments are so important,” said Bandur.
  • Resident Call Systems: Wilson shared that Phase 3 requirements mandate that facilities have a call system that will allow residents to call for assistance either directly to a staff member or to a centralized staff work area from both the bedside and toileting/bathing areas. He also shared a new requirement that the system should be available to a resident who is laying on the floor which may present a challenge for facilities.
  • Training: Phase 3 regulations require that facilities develop and implement training programs. The requirement is not prescriptive about the type or amount of training required. However, it does require that the facility conduct an assessment that will inform decisions on these issues.


Phase 3 Regulations – Solutions

Amongst the Phase 3 regulations is a training requirement. Facilities are required to assess training needs. Based on that assessment, facilities must then develop, implement and maintain a training program for new and existing staff, individuals providing services on a contract basis and volunteers. The training needs to cover:

  • Communication
  • Resident rights and facility responsibilities
  • Abuse, neglect and exploitation
  • Quality assurance and performance improvement
  • Infection control
  • Compliance and ethics
  • Behavioral health

HealthStream's Quality Manager can simplify your facilities path to compliance with tools such as a Facility Assessment and QAPI Plan template that can be filled out and updated annually. “Whenever your surveyors walk in, you are able to simply hand over your QAPI plan – a simple, easy-to-follow guide for quality,” said Wilson. In addition, a mock survey is included. The Quality Manager survey mimics the long-term care survey process that helps identify risk areas.