In October 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule, known as the Mega Rule, that comprehensively revised the conditions required for participation in Medicare and Medicaid programs for long-term care (LTC) facilities. This was the first time in 25 years that sweeping changes were made related to the substantial advances in the theory and practice of service delivery and safety.

The LTC population has changed dramatically over time with a higher incidence of medical complexity and comorbid conditions. Also important to recognize are the updated approaches to improving quality of life, care, and delivery of services. The Mega Rule concentrates on optimizing resident safety, increasing participation in care planning, updating professional standards, and eliminating duplicate processes through the following areas:

  • Infection preventionist
  • Trauma-informed care
  • QAPI program
  • Compliance and ethics program
  • Centralized bedside call system
  • Comprehensive training requirements

Changes to the aspects of LTC services included in the Mega Rule overlap or are sequenced within three phases. The first phase was implemented in November 2016; the second phase was implemented in November 2017; and the third phase (Mega Rule 3) was scheduled to be implemented on November 28, 2019. However, on July 18, CMS issued a proposed rule to delay the implementation of Phase 3 and provided a comment period through September 16, 2019.

CMS announced the proposed delay “to avoid confusion and promote transparency” surrounding certain Quality Assurance and Performance Improvement (QAPI) requirements. CMS is streamlining the QAPI rules and removing detailed requirements. The proposed revisions are intended to allow facilities more flexibility to design and operate programs that meet their residents’ specific needs and diversity, although evidence of compliance will continue to be required. Other areas of revision include:

  • Sending facility-initiated involuntary transfers and discharges to state ombudsmen.
  • Allowing facilities to streamline compliance and ethics programs and reduce frequency of program review.
  • Reinstituting binding arbitration agreements with safeguards on resident communication with state, local, and federal officials.
  • Changing educational requirements for food and nutrition services directors.

In summary, changes to the previous requirements of Mega Rule Phase 3 are yet to be determined with more information to come after the September 16 close date for comments. Nevertheless, it is known that the final phase of the Mega Rule is intended to align clinical standards patterns with current practice patterns. CMS believes this will not only improve the quality of care and services, but will reduce or eliminate procedural burdens, therefore saving time and money. Continued advancement toward integration of these areas will certainly improve the quality of life for residents.

Please contact us if you would like to learn more about how HDG can assist your organization in preparing for this important initiative. For more information, visit our website or contact us at 763.537.5700 or

Authored by: Melissa Hill, RN, MSN, WCC, Director, Clinical Services

Katherine Davis, MS, CCM, CDMS, RCP, CRC, Manager, Consulting Services