The Long-Awaited Phase 3 Requirements Are Now In Effect… But Still No Interpretive Guidance For the Phase 3 Regulations

The Phase 3 requirements went into effect on Nov. 28 as planned and facilities are now required to comply with these and all requirements. In a memo released by CMS on Nov. 22, 2019, CMS stated their ability to survey for compliance with the Phase 3 requirements will be limited until the Interpretive Guidance is released in the second calendar quarter of 2020. They also stated that information on training and implementing related changes to the Long Term Care Survey Process (LTCSP) will be released in second quarter of 2020.

This past summer, CMS issued a proposed rule that would delay implementation of the QAPI and Compliance and Ethics sections of the Phase 3 Requirements, but CMS has yet to finalize that proposed rule. The final rule is not expected to be published until next year, so as of now, facilities are expected to be in compliance with all Phase 3 Requirements, including QAPI and Compliance and Ethics program requirements.

The below checklist summarizes priority actions for complying with the Phase 3 Requirements.

Proactive offers multiple resources to assist with complying with the Phase 3 Requirements, including:

  • QAPI Toolkit designed to assist facilities in maintaining documentation and demonstrating evidence of its ongoing QAPI program that meets the regulatory requirements. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities.
  • Trauma-Informed Care Toolkit designed to assist in meeting the Trauma-Informed Care requirements and demonstrating competency-based training in this area.
  • Moving Mountains Phase 3 RoP Webinar series on-demand trainings


New! Discounted Training Package Phase 3 Essentials. Receive 6 on-demand webinars totaling 10 contact hours of NAB CE for only $429 for a limited time.

These on-demand training sessions from Proactive’s regulatory experts, provide the guidance you need to achieve compliance with the phase 3 Requirements of Participation. Sessions are available for immediate viewing and ongoing access within your organization. With this package you receive the following training topics: Phase 3 – What to Expect, Implementing an Effective QAPI Program, Implementing an Effective SNF Compliance & Ethics Programs, Implementing Successful Staff Training and Competency Programs, Next Steps for the Infection Preventionist, Trauma Informed & Culturally Competent Care. Click here to learn more about this product in our shop.

Get more resources in our shop!

Patients rely on you. You can rely on us. Find toolkits, webinars, on-demand trainings, templates, and much more to meet the needs of your facility. Click here to visit our shop.

Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, Director of Regulatory Services, Proactive Medical Review

Click here to learn more about Shelly and the rest of the Proactive team.