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Competencies for Phase 3 – Requirements of Participation (RoP)

12 May 21


The long-term care industry is finally getting some time to catch their breath and reflect on the tumultuous times of 2020.  Reviewing the 2020 timeline of events may be enough to make your heart race but it is important to evaluate what the industry endured and what is trending now.


If you recall, the Center for Medicare and Medicaid Services (CMS) halted regular surveys in March 2020, shifted to infection control focused surveys, and reverted back to routine surveys in August 2020.  This all happened while long-term care facilities were expected to implement Phase 3 of the Requirements of Participation which includes implementing and documenting competencies.  Facilities were confused because it was unclear if they should embrace competencies based on the infection control survey or the regular survey.   In December 2020, Healthcare Academy hosted a webinar focused on competencies for phase 3 of RoP.  A poll taken during the webinar revealed 75% of webinar participants worked for facilities still under an infection control focused survey.   That was four months after routine surveys were to have resumed which fueled confusion.


Linda Shubert, MSN, RN, and Director of Clinical Management at Healthcare Academy helps long-term care facility leaders make sense of all the competency expectations for Phase 3 of the Requirements of Participation.

Let’s review the definition of ‘competence’ to lay the groundwork for understanding competency requirements.  “Competence is the knowledge, skills, ability, and behaviors that a person possesses in order to perform responsibilities correctly and skillfully” (Olson et al., 2019).  How does competence tie into regulatory requirements?

The regulatory requirements of competencies emphasize the need for long-term care staff to have competencies AND facilities must prove it.  Additionally, there are commonalities between competencies for an infection control survey vs. regular survey and barriers for meeting competency requirements.  Facilities must understand these commonalities and barriers but also know how to step outside of the “one size fits all” approach.  Meaning, facilities need to select competencies specific to their facility and the populations served. Facility specific competencies are most often generated from the annual facility assessment.


As facilities select specific competencies, it is critical to ensure competencies include five core components which are evaluated during a survey.  These components are:

  1. assessment
  2. training
  3. evaluation
  4. feedback
  5. monitoring

These five components are fairly straight forward but the State Operations Manual is not prescriptive about how each of these components should be carried out. Several ideas exist for facilities to adopt each component of competencies and it involves choosing options that are a good fit with each facility’s culture.

Are you feeling overwhelmed??  No sweat, here are a few simple expectations for getting started or moving forward with competency requirements.

  • Develop facility specific policies/procedures; this will help guide which competencies you develop, implement, and monitor
  • Develop specific training tailored to each competency
  • Ensure audit tools are available to check for compliance

Let’s touch base on the audit tools bullet point above.  It is important to bring attention to it because facilities need to differentiate between competency checks that meet regulatory compliance and observational audits that meet ongoing QAPI efforts.  The Agency for Healthcare Research and Quality (AHRQ) put together a simple reference guide to help facilities identify these differences. Click here to learn more about this AHRQ tool.


Competency requirements also includes identifying a target audience for specific competencies.  Phase 3 of the Requirements of Participation was designed primarily for nursing competencies.  COVID-19 elevated this requirement and competencies are now necessary for environmental services, healthcare providers, designated screeners, activities professionals, and family members.  This shift in requirements occurred when facilities received COVID-19 related infection control citations for non-compliance within roles outside of nursing.


Although long-term care facilities should be well underway with implementing and tracking competency requirements, there is a need for facilities to periodically review their ‘competency map’ by evaluating which competencies are essential vs. nice to have.  Survival competencies are a way for facilities to reduce unnecessary tracking of information.  Some survival competencies include those that are:

  • Brief and practical
  • Focused on quality of care and/or safety
  • Built into other activities such as new hire orientation
  • Unit-specific

Ultimately, competent staff are confident staff who are empowered to provide person-centered care.  An April 22, 2021 article in McKnight’s identifies how staff empowerment is linked to positive changes in the long-term care environment and is directly linked to clinical outcomes (de Vilmorin, Stelter & Roth, 2021).


Not sure how to find the right path for your facility with staff competencies? Let us help you assess, remediate, and document staff competency with our Healthcare Academy’s digital competency tool eCompetencies®. Learn more here or contact us to speak to an HCA team member.

The Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) also offer some tools to help you get started:

CDC Targeted Assessment for Prevention (TAP) Strategy Implementation Tools

Infection Control Assessment Tool for Long-term Care Facilities

Nursing home staff competency assessment – CMS: Civil money penalty reinvestment program.


Agency for Healthcare Research and Quality. Competency check vs. observational audit.  Retrieved May 10, 2021 from https://www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/competency-check-vs-observational-audit.pdf

de Vilmorin, C., Stelter, J. & Roth, B. (2021). Staff empowerment is the cornerstone of person-centered care.  Retrieved May 10, 2021 from https://www.mcknights.com/marketplace/marketplace-experts/staff-empowerment-is-the-cornerstone-of-person-centered-care/

Lasek, A. (2021, April 5). AHRQ offers new nursing home audit resources aimed at COVID prevention. Retrieved May 10, 2021 from https://www.mcknights.com/news/clinical-news/ahrq-offers-new-nursing-home-audit-resources-aimed-at-covid-prevention/

Olson, A., Rencic, J., Cosby, K., Rusz, D., Papa, F., Croskerry, P., … & Colford, C. (2019). Competencies for improving diagnosis: An interprofessional framework for education and training in health care. Diagnosis, 6(4), 335-341. Retrieved from https://www.degruyter.com/view/journals/dx/6/4/article-p335.xml

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