April 18, 2017

SNF Requirements of Participation: Don’t Panic, and Trust Your Team

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If you’re like me, you had to read through the Skilled Nursing Facility (SNF) Requirements of Participation (ROP) from the Centers for Medicare & Medicaid Services (CMS) a few times to process all the changes. In a document of nearly 200 pages, three columns and small print, sometimes it is easy to miss a significant change. Let’s take some time to highlight some of these new requirements and how it’s possible to tackle them one at a time.

Consider this: There are three phases to the new requirements.  The first phase went into effect on Nov. 28, 2016. Take a look at the rollout dates for each phase below:

Phase 2 – Nov. 28, 2017
Phase 3 – Nov. 28, 2019

Goals of the SNF Requirements

Let’s start by taking a minute to remind ourselves what the three primary goals of the new ROP are the following:

  1. Person-centered care
  2. Protecting resident rights
  3. Improving quality and safety of residents


Getting Started

In my opinion, the best place to start is with the right team.  These new requirements cannot be implemented with a corporate mandate or just a new set of policies and procedures. These requirements need a complete inter-disciplinary team working together to understand the details in the context of the specifics of your residents and staff at your facility. The team approach is what will make implementing these requirements a success.

Don’t forget, there are a variety of excellent resources available to you as you engage in this process, including summaries provided by American Health Care Association (AHCA), as well as Leading Age and your state associations.

Let’s take a look at some of the highlights in each of the phases:

Phase I Highlights

Phase I implementation is already behind us, but I wanted to point out a few areas just to make sure you noticed them and have new processes in place to address:

  • Note the new and/or enhanced definitions. A few examples:
    • Adverse event
    • Abuse
    • Neglect
    • Person-centered care
  • New Requirement to notify the state long-term care ombudsman of all transfers and discharges
  • Enhanced grievance process, including designation of a grievance official.
  • Updated freedom from abuse, neglect, and exploitation:
    • Facilities must not employ or otherwise engage individuals who have a disciplinary action against their professional license by a state licensure body resulting from abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property
    • Most centers have a great process in place pre-hire, but do you know how you are monitoring to make sure your employees’ license status hasn’t changed during their employment?
Phase II Highlights
  • Clinical P&Ps: There are a number of new or updated clinical policy and procedures.  As a compliance officer, you may not have direct involvement in updating these policies, but assisting by monitoring completion and reviewing final content may provide a valuable asset to the team
  • Facility assessment – In my opinion, the most important requirement in Phase II:
    • Requires a review of your physical properties, equipment, contractors, etc.
    • Requires a review of the acuity and specialty needs of your residents
    • Requires a review of all of your staff both in numbers and qualifications and competencies
Phase III Highlights
  • Compliance and ethics program:
    • Specific requirements if you are part of an organization with five or more centers
    • Delineation of roles and responsibilities for compliance
  • Additional training requirements:
    • Re-organized into one section, which will make it much easier to create your training plan
  • Additional QAPI requirements:
    • Many being implemented in Phase I, but they all come together in Phase III


The Requirements of Participation may feel a bit overwhelming, but if you break the rules into small parts, create an inter-disciplinary team, and make sure to conduct an initial gap assessment, I think you will be surprised at how far along you already are! Many of these requirements are things that you likely have been doing for years without any type of written requirement.

Now you just have to document your processes and take credit!

Donna Thiel, CHC

Donna Thiel is the director of the compliance integrity team, a consulting division of ProviderTrust. Donna assists compliance officers Byproviding consulting services in areas such as strengthening compliance programs, managing government investigations, implementing and managing a Corporate Integrity Agreement and preparing for the various regulatory changes that impact healthcare providers. 

This email address is being protected from spambots. You need JavaScript enabled to view it.

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