Are You Ready for the Phase 2 November 28th Deadline?

If you are a skilled provider, you are actively thinking about November 28th.  It is most likely keeping you up at night. For those that are not in the loop, November 28th is the due date for Phase 2 completion of CMS’ new requirements for participation. If this is not something you’re taking seriously or actively working on well before November, you may want to keep reading.

RoP Summary

On October 4, 2016, CMS published in the Federal Register the final rule on the Requirements of Participation (RoP) that long-term care facilities must meet to participate in the Medicare and Medicaid programs. This rule represents the most comprehensive update to the RoP since the 1990’s. CMS explained that the changes to the requirements are needed keep pace with the changes in the industry and assist in the goal of improving the provision of health care and patient safety.

A major theme of the new requirements is person-centered care, with an emphasis of residents and their representatives being informed, involved, and having control. You will see examples of this person-centered emphasis in the care planning and discharge planning requirements. The facility assessment is integrated throughout multiple sections of the RoP. The purpose of the facility assessment is to ensure that facilities have sufficient number of staff who are competent to meet the needs of the population the facility serves and that facilities have appropriate resources to meet the needs of their population on a day-to-day basis and in emergency situations.

The RoP is effective in three phases:

  • Phase 1: CMS contends that these requirements are relatively straightforward to implement, and require minor changes to survey process. They were effective November 28, 2016.
  • Phase 2: Includes the requirements that CMS felt providers need more time to develop and will include a new survey process to assess compliance. These requirements are effective November 28, 2017.
  • Phase 3: These are the requirements that need more time to implement and may require personnel hiring and training and implementation of systems approaches to quality. Facilities must comply with these requirements by November 28, 2019.

The RoP is expansive and cannot be easily summarized. We expect that CMS will issue interpretive guidance to assist providers in complying with the new requirements.

Although CMS contends the Phase 1 Requirements are relatively straightforward to implement and require only minor changes to the survey process, providers need to review their policies and procedures and make revisions to ensure compliance.

Phase 1 included many obligations regarding admissions, transfer and discharges, care planning, the use of side rails, as well as many updates to resident rights, abuse procedures and definitions, grievance process requirements, and various other changes. It is imperative that facilities evaluate their current policies and procedures, facility postings, and admission process to ensure compliance with the Phase 1 requirements.

To prepare for the Phase 2 implementation date, which is mere months away, facilities should establish a Phase 2 work plan to accomplish the many tasks required for compliance. This will include:

  • Completing a facility assessment to ensure the facility has the appropriate resources and competent staff to meet the needs of its population.
  • Developing the written QAPI plan to present to surveys on the next annual survey.
  • Implementing an antibiotic stewardship program.
  • And many other changes in current processes which includes a 48-hour initial care plan.

Creating a sound QAPI program is one of the largest components of this task list. If you haven’t already, look for Lean Six Sigma and QCP (QAPI Certified Professional) certifications that may be offered through various state and national associations. CMS doesn’t specify which method is preferred, but encourages formalized process improvement training in order to implement at successful and integrated QAPI program.

In conclusion, the new requirements have very broad implications on facility operations and administration and facilities will need to allocate additional resources to ensure compliance.  We suggest developing a RoP Implementation Team that is focused on driving a RoP implementation work plan targeted at accomplishing required actions for each phase of implementation. Many of the changes will require updates to policies and procedures, new or revised training, comprehensive systems review, formal notices to residents, and impact daily care processes.

HTS is assisting our clients through this RoP process by partnering with Proactive Medical Review who offers a partnership plan for assisting clients through each phase of implementation.
This plan includes a facility-specific needs assessment and detailed implementation guidance, as well as:

  • Off-site policy and procedure review in each implementation area with redline suggestions for meeting the updated requirements. Policy templates will be provided as needed based on the policy/procedure gap analysis.
  • Implementation site visit and training options.
  • Access to our implementation checklists, timelines, and updated resident notices which meet RoP requirements, as well as training tools and resources.

It’s an “all hands on deck” world to meet the RoP Phase 2 deadline. We encourage you to act now by seeking proper education and forming your committees and to not wait until September to make this happen. November 28th will be here before you know it.

Guest Blog

Article co-written by:

Cassie Murray, OTR/L, QCP
Exec Director of Clinical Operations, Healthcare Therapy Services, Inc. | 800-486-4449 ext 210


Shelly Mafia, MSN, MBA, NHA, QCP
Director of Regulatory Services, Proactive Medical Review  |  812-471-7777

As many as one million people in the US are living with Parkinson’s disease (PD). Parkinson’s is a chronic and progressive movement disorder, meaning the symptoms continue and worsen over time. The average onset for all people with Parkinson’s is age 60 and although there is no cure for the disease, there are treatment options to help manage the symptoms.

Early Warning Signs
It’s important to recognize the early warning signs of PD. An early diagnosis may help slow the onset of the disease. Some of these symptoms are normal signs of aging. If you have more than one symptom or a symptom persists, talk with your doctor.

  • Tremor or Shaking
  • Dizziness or Fainting
  • Trouble Moving or Walking
  • Loss of Smell
  • Trouble Sleeping
  • Constipation
  • Soft or Low Voice
  • Change in Handwriting


How Can Therapy Help?
Taking advantage of the expertise of a team of professionals can be very beneficial for somebody living with Parkinson’s. In addition to a specialized neurologist, physical, occupational and speech therapy can effectively manage the symptoms and side effects of PD to maximize quality of life.

Physical Therapy
A Physical Therapist (PT) is trained to work with individuals to regain and maintain mobility. A PT can develop customized exercise programs to address balance problems, lack of coordination, fatigue, pain, gait, immobility, and weakness.

Occupational Therapy
Occupational Therapists (OT) can help modify your environment and daily activities in order to accommodate your changing needs. Occupational therapy focuses on helping you maintain your independence.

Speech Therapy
A Speech-language Pathologist (SLP) can help improve Parkinson’s disease speech problems and provide coping strategies for those who have trouble swallowing.


If you or a loved one has been diagnosed with Parkinson’s disease, talk with your doctor about the benefits of physical, occupational and speech therapy.

Source: Parkinson’s Disease Foundation


In today’s climate of scrutiny and burden of justifying therapy services and skilled stays, it is becoming increasingly critical for nursing to take charge in documenting each patients’ skilled needs. Specifically, what should the nurses be documenting in the medical record? How specific is the training for your nursing staff?

Before you answer, remember that the rules of documentation have changed greatly in the past 3 years. Even now, something that is the norm could likely be scrutinized in future audits. Whether you’ve had ADRs and denials for payment, it’s not a matter of if…but when. Those of us that are laser focused on the regs and changing climate of our industry know why things have altered so greatly. However, I have found that keeping to the basics is the best way to explain documentation expectations that are critical for justifying a skilled stay. I have also had my own documentation scrutinized, reviewed my fair share of ADRs and audited countless charts for congruent nursing and therapy documentation. The ideas below are a culmination of questions, mistakes, training and conversations by nurses, administrators and corporations. Try using these proven strategies to improve your skilled nursing documentation to support therapy services, and ultimately support the skilled stay:

The Do’s and Don’ts:



Justifying a Skilled Stay:

Nurses must ask themselves the following questions (and document the answers) each and every day:

  • Why is this patient here?
  • What is preventing this patient from going home right now? Could this patient go home right now and be safe and independent? Why not?
  • What are you doing that would not or could not happen for this patient at home?
  • Have you noticed this patient improving in any aspect of mobility? Self-care? Communication?
    *Even minor improvements need to be noticed and documented.
  • Why is this patient receiving PT, OT or ST?
  • What would/could happen if this patient was not an inpatient receiving care?
  • What are all of the medical complexities that are impacting this patient’s recovery. Explain the multiple conditions that you are managing. What is making this patient’s recovery take this amount of time?


RUG Supportive Documentation: Do they know the Why?

  • Do your nurses know what a RUG level is? Try asking several nurses on your rehab unit if they know what a RUG level is…you may be surprised by how many do not know. Do your nurses understand the importance of ADL coding?  Nurses need to understand the basic reimbursement system for the stay in order to understand the importance of the documentation. Provide a basic PPS inservice to help your staff understand how the MDS, nursing notes and therapy notes combined determine the RUG level. The medical record must make sense—nursing notes and therapy notes must support the coding on the MDS.
  • Do your nurses understand that PLOF is critical for establishing all goals? What was the patient doing prior to the hospitalization? Was he/she completely independent with all self-care and mobility? What about higher level tasks—grocery shopping, driving, cooking, laundry?
  • What does the patient need to be able to safely do prior to returning home? What impairments are preventing the patient from doing these things?
  • Are your nurses documenting their skilled nursing interventions? What if therapy services are denied? Will your nursing documentation prove a skilled nursing level? Provide nursing education regarding specific skilled nursing interventions. Provide sample documentation that reflects skilled nursing interventions.

I hope that these tips and questions help to gauge the level of training and direction for our SNF nurses. Now more than ever, you deserve to be paid for the great care you provide.

HTS is committed to the success of our clients and partners. That is why we provide on-going support and education for our therapists, nurses, and the entire IDT. With the changing expectations for justified skilled stays, make sure you are partnered with a dynamic, progressive therapy provider who will support and enhance your position in our post-acute care market.

Guest Blog

Cassie Murray, OTR, QCP, IASSC CYB 
Cassie Murray is the Executive Director of Clinical Services for Healthcare Therapy Services. A 1994 graduate from Indiana University in Occupational Therapy, Cassie has over 22 years of experience in long term care, hospital, outpatient and home health. She provides support for HTS therapists and partnering communities through program development, training on regulatory requirements and ongoing quality assurance. She is active in state and national associations such as Leading Age, AHCA, NASL, AOTA. Her passion for rehabilitative services is inspired from personal experience with her father suffering a stroke while Cassie was in high school. This led to her successful career path in occupational therapy.

To contact the author: | 800-486-4449 ext 210 |