Harmony Healthcare Blog

Requirements of Participation (RoP): Overview Phase III

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Thu, Mar 28, 2019

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Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency

Online Sells - Business Concept. Button on Modern Computer Keyboard. 3D Render.Phase III
Requirements of Participation (RoP)
Implemented by November 28, 2019 


  1. QAPI Plan/Program Governing Body
  2. Person-Centered Care Planning
  3. Trauma Informed Care / Behavioral Health Services for History of Trauma PTSD
  4. Infection Preventionist
  5. Compliance and Ethics Program
  6. Physical Environment
  7. Training Requirements Competencies of Staff
  8. Dietary 

Click Here to Register for our Free Requirements of Participation (RoP) Webinar on 3/29/19

  1. Quality Assurance and Performance Improvement (QAPI) (483.75)
  • Requires all LTC facilities to develop, implement, and maintain an effective comprehensive, data-driven QAPI program that focuses on systems of care, outcomes of care and quality of life.
  • Requires facilities to include mandatory training as a part of their QAPI and infection prevention and control programs that educate staff on the written standards, policies, and procedures for each program.
  1. Person-Centered Care Planning Baseline Care Plan requires facilities to develop a baseline care plan for each resident, within 48 hours of their admission, which includes the instructions needed to provide effective and person-centered care that meets professional standards of quality care.
    • PASARR adds a requirement to include as part of a resident’s care plan any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record.
    • Interdisciplinary Team (IDT)
      • Adds a nurse aide, a member of the food and nutrition services staff, and a social worker to the required members of the interdisciplinary team that develops the comprehensive care plan.
      • Requires facilities to provide a written explanation in a resident’s medical record if the participation of the resident and their resident representative is determined to not be practicable for the development of the resident’s care plan. 
    • Discharge Planning
      • The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT 2014) (Pub. L. 113-185) amended Title XVIII of the Social Security Act by, among other things, adding Section 1899B to the Social Security Act. Section 1899B(i) requires that certain providers, including long term care facilities, take into account, quality, resource use, and other measures to inform and assist with the discharge planning process, while also accounting for the treatment preferences and goals of care of residents.  This section implements the discharge planning requirements mandated by the IMPACT Act by revising, or adding where appropriate, discharge planning requirements for LTC facilities. 
      • Requires facilities to document in a resident’s care plan the resident’s goals for admission, assess the resident’s potential for future discharge, and include discharge planning in the comprehensive care plan, as appropriate.
      • Requires that the resident’s discharge summary include a reconciliation of all discharge medications with the resident’s pre-admission medications (both prescribed and over-the-counter).
      • Adds to the post discharge plan of care a summary of what arrangements have been made for the resident’s follow up care and any post-discharge medical and non-medical services. 
  1. Trauma Informed Care
  • Adds a new section that focuses on the requirement to provide the necessary behavioral health care and services to residents in accordance with their comprehensive assessment and plan of care.
  • Staffing
    • Facility assessment requires facilities to determine their direct care staff needs, based on the facility’s assessment.
    • Competency approach requires that staff must have the appropriate competencies and skills to provide behavioral health care and services, which include caring for residents with mental and psychosocial illnesses and implementing non-pharmacological interventions.
    • Social worker adds “gerontology” to the list of possible human services fields from which a bachelor degree could provide the minimum educational requirement for a social worker. 
  1. Infection Control
  • Require facilities to have a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under an arrangement based upon its facility and resident assessments that is reviewed and updated annually.
  • Requires facilities to designate an IPCO for whom the IPCP is their major responsibility and who would serve as a member of the facility’s quality assessment and assurance (QAA) committee. Each facility must have an infection prevention and control officer with specialized training; a system of surveillance is required.
  1. Compliance and Ethics Program (483.85)
  • Requires the operating organization for each facility to have in operation a compliance and ethics program that has established written compliance and ethics standards, policies and procedures that are capable of reducing the prospect of criminal, civil, and administrative violations in accordance with section 1128I(b) of the Act. 
  1. Physical Environment
  • Call System from each Resident’s Bedside
  • Resident Rooms – requires facilities initially certified after the effective date of this regulation to accommodate no more than two residents in a bedroom.
  • Toilet Facilities – requires facilities initially certified after the effective date of this regulation to have a bathroom equipped with at least a toilet, sink and shower in each room.
  • Smoking – requires facilities to establish policies, in accordance with applicable federal, state and local laws and regulations, regarding smoking, including tobacco cessation, smoking areas and safety.

  1. Training Requirements
  • Requires an effective training program that facilities must develop, implement, and maintain for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Training topics must include-
    • Communication – requires facilities to include effective communications as a mandatory training for direct care personnel.
    • Resident Rights and Facility Responsibilities – requires facilities to ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents as set forth in the regulations.
    • Abuse, Neglect, and Exploitation – requires facilities, at a minimum, to educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, and procedures for reporting these incidents.
    • QAPI & Infection Control – requires facilities to include mandatory training as a part of their QAPI and infection prevention and control programs that educate staff on the written standards, policies, and procedures for each program.
    • Compliance and Ethics – requires the operating organization for each facility to include training as a part of their compliance and ethics program. Requires annual training if the operating organization operates five or more facilities.
    • In-Service training for nurse aides – requires dementia management and resident abuse prevention training to be a part of 12 hours per year in-services training for nurse aides.
    • Behavioral Health training – requires facilities to provide behavioral health training to its entire staff, based on the facility assessment as 483.70(e).
    • Nurse Aide Training on areas of weakness determined by performance reviews and the facility assessment 483.95(g)(3) 
  1. Dietary
  • Staffing- requires facilities to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the dietary service while taking into consideration resident assessments, and individual plans of care, including diagnoses and acuity, as well as the facility’s resident census.
  • Dietitian Qualifications – clarifies that a “qualified dietitian” is one who is registered by the Commission on Dietetic Registration of the Academy of Nutrition and Dietetics or who meets state licensure or certification requirements. For dietitians hired or contracted with prior to the effective date of these regulations, we propose to allow up to 5 years to meet the new requirements. 
  • Director of Food Service- adds to the requirement for the designation of a director of food and nutrition service that the person serving in this position be a certified dietary manager, certified food service manage, or have a certification for food service management and safety from a national certifying body or have an associate’s or higher degree in food service management or hospitality from an accredited institution of higher learning. In states that have established standards for food service managers, this person must meet state requirements for food service managers.
  • Menus and Nutritional Adequacy - adds to the requirements that menus reflect the religious, cultural and ethnic needs and preferences of the residents, be updated periodically, and be reviewed by the facility’s qualified dietitian or other clinically qualified nutrition professional for nutritional adequacy while not limiting the resident’s right to make personal dietary choices.
  • Providing Food and Drink – adds to the requirements that facilities provide food and drink that take into consideration resident allergies, intolerances, and preferences and ensure adequate hydration.
  • Ordering Therapeutic Diets – allows the attending physician to delegate to a registered or licensed dietitian the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by state law.
  • Frequency of Meals – requires facilities to have available suitable and nourishing alternative meals and snacks for residents who want to eat at non-traditional times or outside of scheduled meal times in accordance with the resident’s plan of care.
  • Use of Feeding Assistants – requires that facilities document the clinical need of a feeding assistant and the extent to which dining assistance is needed in the resident’s comprehensive care plan.
  • Food Safety
    • Clarifies that facilities may procure food items obtained directly from local producers and are not prohibited from using produce grown in facility gardens, subject to compliance with applicable safe growing and food handling practices.
    • Clarifies that residents are not prohibited from consuming foods that are not procured by the facility.
    • Requires facilities to have a policy regarding the use and storage of food brought to residents by family and other visitors. 

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have. You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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