Roll out of the Centers for Medicare & Medicaid Services’ (CMS’) final rule on requirements of participation for nursing homes will take place over the next two years via a three-phase process, according to Karen Tritz, CMS director of the Division of Nursing Homes.

Speaking at the Jan. 31 meeting of the Advancing Excellence in Long Term Care Collaborative (AELTCC), Tritz emphasized the group’s importance to the agency’s implementation and information gathering process. She asked members for feedback and input as CMS tackles what appears to be the simultaneous launch of multiple new initiatives related to the rule.

In addition to new interpretive guidance and revised f-tag numbers, nursing homes in all 50 states will see a new survey process by the end of Phase II, in Nov. 2017, Tritz reported.

Also scheduled for completion by the end of Phase II is an updated State Operations Manual (SOM), with an advance copy of it to be publicly available by early this summer.

Tritz offered the following overview of the rule, which she noted is the result of a number of provisions from the Affordable Care Act (ACA) and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which include the following compliance and ethics programs:

  • Quality Assurance and Performance Improvement (QAPI);
  • Reporting suspicion of a crime;
  • Increased discharge planning requirements; and
  • Staff training.

“Think of the rule as raising the bar on quality,” Tritz told the room full of roughly two dozen representatives of stakeholders in post-acute and long-term services and supports.

AELTCC member Cheryl Phillips, MD, senior vice president of Public Policy & Advocacy for LeadingAge, expressed apprehension about the rule’s emphasis on holding providers more accountable for resident discharges. “I am concerned about a discharge when an individual elects to go to a setting that we would not select for them,” she told Tritz. “The way the regulatory language appears now is that if a nursing home is participating in the discharge in any way—even if they are attempting to make a bad discharge as good as possible—then they are held accountable for a bad outcome.”

Tritz acknowledged Phillips’ concern as legitimate and offered clarification: “If the individual wants to go, you’re not going to keep them,” she said. “So we would look at what the documentation and discussion to determine that it’s very clear that you would not have chosen this setting.”

Len Russ, American Health Care Association immediate past-chair, suggested that the advent of managed care and other payment models could further complicate discharge issues, particularly because corporate office MCO staff appear to be making decisions about discharges while the nursing home must bear responsibility for implementing them. “They have no consequences,” Russ said, referring to the managed care entities. “It appears that the rule will sometimes hold facilities responsible for decisions that they don’t make. From a regulatory standpoint, [MCOs] are increasingly the ones making the decision, while clinicians are having less and less decision making power.”

Tritz noted that Russ’ point was well taken, adding that she is interested in “where there are intersections and disconnects with regard to his concerns and the regulations.”

The new regulations also have the potential to impact certified nurse assistants (CNAs) across a number of areas, including their formal inclusion in the interdisciplinary team for care planning, the performance improvement process, and a number of additional educational requirements in the coming years.

Overall, AELTCC members were impressed with Tritz’ presentation as well as the ability to have an open and honest discussion that only the Collaborative can facilitate. A number of members expressed appreciation for their ability to have personal and direct interactions with CMS, as it allows them to prepare their constituents as they continue along the journey toward full implementation of the new rule.

For her part, Tritz was appreciative of the Collaborative’s feedback, especially given that it represents a uniquely broad array of stakeholder perspectives.


Lori Smetanka, Executive Director, The Consumer Voice

The dialogue with Karen Tritz from CMS on the Long Term Care Requirements of Participation hosted by the Advancing Excellence Collaborative provided a useful opportunity to hear the perspectives of a variety of stakeholder representatives on the new rule and the effects of its implementation. Representing consumers of nursing home services, we believe the rule includes important needed protections, including the requirement for a baseline resident assessment, additional protections around involuntary discharge and abuse, and requirements related to staff training and competencies.

Barbara Bowers, American Academy of Nursing

While we might not all agree on whether staffing levels should be mandated, we all agreed that staff at all levels do not have access to sufficient educational opportunities. Meaningful education is related to the challenges of day to day work, the things experienced by staff as relevant to what they do. This is often not the case with ‘mandated training programs.’ Educational opportunities improve care quality and send a message to staff that they are worth investing in.

We all agreed that more needs to be done about the transfer of residents from acute care settings. The often disorganized, contradictory pile of papers or attachments that arrive becomes a huge time sink that results undermines both care quality and morale.

Many families come to SNFs with unrealistic expectations about the resources available. They often expect something very much like the hospital setting they may have just left. Hospital personnel often contribute to this misinformation, leading to disappointment and anger on the part of families. Better training of hospital staff about what a long-term care facility is, how it is staffed, what is and is not available, would decrease these problems.

Gina Zimmermann, Executive Director, Business Development - Nursing Care Center Services, The Joint Commission

The Advancing Excellence in Long Term Care Collaborative recently provided an excellent opportunity for industry leaders to openly dialogue with Karen Tritz, Director of CMS’ Division of Nursing Homes, about the new regulations for long term care facilities. From The Joint Commission’s perspective, we believe that although the magnitude of changes in regulations facing the industry are great, reform of the long term care requirements was necessary to improve both the quality and safety of care for nursing home patients and residents. Substantial advances have been made in the theory and practice of service delivery in the long-term care setting over the past many years, and it is important to periodically make changes to regulations and standards to reflect changes in the industry. The dialogue in our meeting was welcome, as all of the AE Collaborative member organizations work to support nursing homes and care providers in complying with the new regulations. It was rewarding to see leaders representing the various member organizations focused on a common goal of improving patient and resident outcomes in the long-term care setting.

Cheryl Phillips, MD, Senior VP, Public Policy and Health Services, LeadingAge

The dialogue between CMS, providers, health professionals, consumer advocates, labor and business demonstrated the real value of this AELTC stakeholder constituency. It allowed CMS to hear a broad range of issues and perspectives, and it also allowed for the AELTC members to better understand unique issues facing Nursing Homes and the efforts to improve regulatory oversight. I would hope that such dialogue with regulators can continue, as we all work together to achieve better quality of care and life for people living in nursing homes, their families and the staff who care for them.

Jay Sackman, Representative, The New Jewish Home

The meeting with Karen Tritz demonstrated that the Advancing Excellence in Long Term Care Collaborative is much more than the sum of its’ parts. Because of our inclusive culture, our members could have an open and honest discussion with Karen and with each other. This deepened our understanding of the new rule as well as each other’s perspectives about the rule and other related issues.

Jeffery S Wellman, MSHRD, National Steering Commission Co-Chair, National Association of Health Care Assistants

Karen Tritz, Director of Division of Nursing Homes, CMS, shared important information regarding the progress of implementation of the new Requirements of Participation for nursing home. The new RoPs have the potential to impact our members (CNAs), formal inclusion in the IDT for care planning, inclusion in the Performance Improvement Process and finally, there will be a number of additional educational requirements in the coming years. AELTCC is very fortunate to have had this personal and direct interactions with CMS because it will allow the collaborative and its members to help prepare their constituents to continue along the journey toward full implementation of the new regs.

Randy Lindner, President and CEO, Foundation of the National Association of LTC Administrator Boards

CFR 42 Part 418 as adopted in 1970 established a requirement for licensure of skilled nursing facilities with the requirement of licensure including the requirement of having a licensed nursing home administrator. The new Requirements for Participation specify that nursing homes or other organizations providing nursing services comply with CFR 42. However, assisted living and home and community based services have not had to meet this requirement despite significant job similarities.

With an aging leadership workforce and the difficulty of attracting candidates into the profession of long term care administration, the ability to access CMP funds at the state and Federal level to provide financial support for education and during the administrator-in-training experience (AIT) would assist in addressing, the financial barriers to entry into the profession, contribute to a high level of leadership and enhance quality of care.

The NAB has taken the lead in preparing our leadership workforce to lead organizations providing multiple lines of long term care support and service with the establishment of a broad-based qualification, the Health Service Executive (HSE). The HSE recognizes new education and training models, broadens the competency of LTC administrators, addresses the issue of cross boarder mobility and enhances the image of the profession.

For full statement, please click here.

Christopher E. Laxton, CAE, Executive Director, AMDA – The Society for Post-Acute and Long-Term Care Medicine

It is meaningful to me that Karen Tritz, Director of the Nursing Home Division at CMS, found that AELTCC was a valuable stakeholder forum, to come to our meeting in person and provide us with an update on the implementation of the new nursing home rule. I was additionally impressed that she brought a number of questions that she felt our collaborative, with its unique and diverse membership, was in a strong position to respond to.

As the discussion progressed, it became clear that a two-hour meeting, while substantial, could only scratch the surface of the many issues at play in implementing the new rule. Ms. Tritz acknowledged this and invited additional comment and feedback from AELTCC members, either individually or collectively. I found this to be a heartening acknowledgement that our collaborative represents a valuable, relevant force for improvement in nursing home care. We continue to be strengthened and enriched by our diversity.

I am grateful to have this reflected by CMS. After she had concluded her remarks, I asked Ms. Tritz how she felt AELTCC could be helpful to her and her colleagues at CMS. She replied that she hoped AELTCC would continue to provide a forum for ongoing discussion and feedback on trends in PA/TC settings of care, and regulatory initiatives responsive to the needs of beneficiaries. This is well aligned with AELTCC’s mission and purpose.

David Gifford, MD, Senior Vice President Quality & Regulatory Affairs, American Health Care Association

AHCA welcomed the opportunity to participate in the conversation with CMS along with the diverse AELTCC members. CMS provided context for the new Rules and the members of the collaborative provided feedback from the perspectives of providers, consumers, professional associations and academic institutions. It was the type of open and honest discussion that only the Collaborative can facilitate.