The time has arrived...(and I'm not referring to the holiday season). As of yesterday, Phase I of the Requirements of Participation (RoP) for Long-Term Care Facilities went into effect.

Not only do we have a large volume of changes to contend with, some regulations begin in Phase I, with additional implementation steps in Phase II or III. With so many regulations changing at one time, knowing where to start can be a challenge. For anyone looking for some guidance to assist in your strategic planning, I propose you start with the end. What will the state surveyors be looking for when they are reviewing for facility compliance with the Phase I RoPs?

Fortunately, the Center for Medicare and Medicaid Services (CMS) training materials for state surveyors are publicly available. In addition, some draft guidance has been issued by CMS through an advanced copy of revisions to the State Operating Manual (SOM) including Appendix PP, "Guidance to Surveyors for Long Term Care Facilities." If you don't have time to wade through the SOM (or even if you do), I strongly encourage you to take 58 minutes out of your busy day to review the CMS YouTube training video, "Long Term Care Reform Phase 1 Regulations and F Tags."

The video is actually a very digestible Power Point, and could pair well with a buttery bowl of popcorn. The first five minutes provide a concise, visually interesting interpretation of the regulatory groupings with respect to Phase I. The video then goes into each relevant section and specifically tells surveyors what key points to look for and which F-Tags they should use for survey. While it is not entirely explicit on what types of documentation or support providers will need to share with surveyors, it provides you a pretty good list of what CMS expects the surveyors to look for.

If you have a little more time to spare (and are not particularly interested in popcorn), you should take at least a cursory look at the advanced copy of the State Operating Manual (SOM) with draft Appendix PP.

While much of the SOM is restating the new regulations, I personally found the draft interpretive guidelines and procedures for surveyors helpful.

For those of you who would like a sound bite or two, here are a couple of big things you should know:

• Because the Center for Medicare and Medicaid Services (CMS) has not yet released new interpretive guidance, nursing home surveyors are being instructed to use current F-Tags if they find a deficiency related to the new RoPs.

• There will be a complete overhaul of F-Tags for Phase II which begins November 28, 2017. For this reason, the advanced Copy of Appendix PP must be used for surveys occurring on and after November 28, 2016, but it will be replaced in a year.

• A large focus of Phase 1 is centered on resident rights. These are just a few instructions provided to surveyors in Appendix PP:

• ​Pay close attention to resident or staff remarks and staff behavior that may represent deliberate actions to promote or to limit a resident’s autonomy or choice.

• Look, particularly during observations and record reviews, for on-going efforts on the part of facility staff to keep residents informed.

• Look for evidence that information is communicated in a manner that is understandable to residents and communicated at times it could be most useful to residents, such as when they are expressing concerns, or raising questions, as well as on an ongoing basis.

• If during a brief record review it is found a resident has an advance directive, is participating in experimental research, refused medical or surgical treatment, received or is currently receiving life sustaining treatments, the surveyor(s) should conduct observations, interviews and record reviews.

• Phase I also focus on policies, plans, and documentation. While there are many areas where surveyors are instructed to "ensure" things like sufficient staff and governing board oversight of administrators, there are also areas where the surveyors are instructed to look for documentation and policies. This is the case for discharge planning, care planning, medication regimen review (pharmacy services), and infection control.

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