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By October 6, 2016January 2nd, 2019Compliance & Ethics, Survey & Enforcement

Major reform to nursing facility requirements of participation require prompt action by nursing facilities nationwide

On October 4, 2016, CMS published major changes to the Requirements of Participation (“RoPs”) for Long-Term Care Facilities. (See HERE for a full version of the new rules). These revisions mark the first changes to the RoPs in 25 years and require nursing facilities to abide by new requirements, update existing policies, procedures, and agreements, implement new programs, and provide additional information to residents.

The changes to the RoPs are so numerous that CMS is “phasing in” the changes over a period of 3 years.  The first phase of changes, however, is forthcoming in less than 60 days.  Phase 1 of the new RoPs is effective November 28, 2016.

The following is an overview of just some of the things SNFs will need to put in place during Phase 1:

  • Abuse
    • Update policy with new definitions and reporting requirements
  • Care Planning
    • Policy and admission agreement updates addressing resident participation in care planning process, and acknowledgment of the same
  • Grievances
    • Written policy addressing specific required procedures for prompt resolution of resident and family grievances
    • Designation of Grievance Official
    • Posting contact information identifying how to file grievances on abuse and neglect
  • Discharge
    • Update discharge notice and procedure
    • Develop and implement a discharge planning process that includes required specific, detailed discharge summary information
  • Pharmacy
    • Policy addressing new requirements for monthly drug reviews
    • Updated procedure for pharmacy reporting irregularities and facility response to the same
    • Policy and procedure for educating residents on vaccines and documented refusals
  • Infection Control
    • Updated policy describing system for identifying, investigating and controlling infections and communicable diseases for residents, staff, volunteers, visitors and others
    • Policies and procedures that specifically include: surveillance, identification, reporting, standard and transition based precautions and isolation
  • Arbitration Agreement
    • Must be removed from new admission agreements signed after 11/28/16 (unless a nationwide injunction is issued before then)
  • Entrapment
    • Must conduct regular inspections of bed frames, mattresses and bed rails
  • Resident Rights – New procedures/notifications for:
    • Visitation
    • Rules governing resident conduct
    • Admissions process
    • Smoking policy
    • Replacement of lost/damaged resident property
  • Quality Assurance
    • Requires new QA members to be on committee

Remember that this is only a flavor of the full extent of work ahead of SNFs over the next two months. Facilities need to get up to speed very quickly in order to meet the November 28, 2016 initial deadline.

If you have questions regarding the new rule, please contact Carol Rolf at or Michele Conroy at

Please note that this alert is intended to be informational only, and is not intended to be nor should it be relied upon as legal advice.  Rolf Goffman Martin Lang LLP will not be responsible for any actions taken or arrangements structured based upon this alert.  The receipt of this alert by an organization that is not a current client of Rolf Goffman Martin Lang LLP does not create an attorney-client relationship between the recipient and the law firm.

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