Phase 3 Requirements of Participation (RoP) - 11/28/19 Effective Date

CMS’ Director, Division of Nursing Homes – Evan Shulman provided some clarity around the Phase 3 Requirements of Participation eff date of 11/28/19 in October of this year at the Leading Age National Conference. He shared that while Phase 3 of the RoP remains effective as of 11/28/19, there is not a date yet for the release of guidance and implementation for Surveyors. CMS is determining how these Phase 3 requirements relate to other initiatives in place such as QAPI and the reduction of burden in combination with PDPM.


Stressed was the importance of moving forward with having an Infection Preventionists identified on staff and to have them take CMS’ training. The #1 citation remains infection control (hand washing – “Alcohol based hand rubs are the preferred method”)

Phase 3 Requirements of Participation include:

  • Compliance and Ethics Program

  • Physical Environment

  • Dietary

  • QAPI

  • Person Centered Care Planning/ Trauma Informed Care

  • Infection Preventionist

  • Training Requirements for Staff Competencies

Let's Get to the Point:

While there are calls out to CMS for delays on the Enforcement of all Phase 3 requirements, CMS has not provided clarification on how compliance will be assessed, and we stand at 11/28/19 with Phase 3 facing us. Hoping this checklist helps provide clarity.