Dealing with Quality Assurance and Performance Improvement (QAPI) compliance isn’t exactly new—but the Centers for Medicare & Medicaid Services (CMS) has recently thrown you a curveball. In an effort to help nursing facilities cultivate a proactive QAPI culture, the agency has unveiled new requirements. Here’s what you need to know:
What’s new: CMS recently created new QAPI requirements for the long-term care (LTC) survey process, including adding 41 new Critical Element Pathways (CEPs), explains healthcare compliance expert Carmen Bowman in her webinar, “How to Implement a Proactive QAPI Culture and Be Your Own Surveyor.” The CEPs are tools for surveyors to ensure that your nursing facility is up to snuff on your quality efforts and beyond.
Understand the CEPs & F-Tag Changes
The new LTC survey process, which became effective on November 28, 2017, combined elements of the traditional survey and the Quality Indicator Survey (QIS), according to the CMS Compliance Group, Inc. (CCG). The long list of CEPs guides surveyors through the process. Some of the CEPs include:
- SNF Beneficiary Protection Notification Review
- Dining Observation
- Infection Prevention, Control, and Immunizations
- Kitchen Observation
- Medication Administration Observation
- Resident Council Interview
- Activities of Daily Living (ADL)
- Environmental Observations
- Sufficient and Competent Nursing Staffing Review
First: But before you address the CEPs, you should evaluate the federal regulatory requirements (F-tags), according to a Pennsylvania Association of Directors of Nursing Administration (PADONA) Annual Convention presentation by Sophie Campbell of Baker Tilly Virchow Krause LLP. Specifically, study the F-tags’:
- Regulatory intent
- Definitions in the regulation
- Interpretive guidance
- Investigative summary and probes
- Key elements of noncompliance (new section added to some F-tags)
- Potential tags for additional investigation
Check Out the Surveyor QAA/QAPI Worksheet
Not surprisingly, surveyors’ new CEPs also include the Quality Assessment and Assurance (QAA) and QAPI Plan Review. The surveyor worksheet divides the QAA review and QAPI Plan review into two sections that aim to determine whether your facility meets the CMS nursing requirements.
Self-evaluate: In the section for the QAPI Plan review, surveyors will specifically look for the following:
- Does the QAPI Plan have policies/protocols describing how it will:
- Track and measure its performance?
- Establish goals and thresholds for performance measurement?
- Identify and prioritize deviations from performance and other problems and issues?
- Systemically investigate and analyze to determine underlying causes of systemic problems and adverse events?
- Develop and implement corrective action or performance improvement activities?
- Monitor and evaluate the effectiveness of corrective action/performance improvement activities?
- Does the facility have a QAPI Plan containing the necessary policies and protocols describing how they will identify and correct their quality deficiencies?
Be prepared: Within just four hours of a surveyor’s arrival at your nursing facility, you will need to provide your QAPI Plan and QAA committee information. This is outlined in the CMS Entrance Conference Form.
Surveyors will also ask for your Infection Prevention and Control Program and Antibiotic Stewardship Program standards, as well as policies and procedures. You’ll need to provide your Influenza/Pneumococcal Immunization policy and procedures as well.
What’s more: Surveyors will want to see that your QAPI committee demonstrates “good faith attempts” to identify and correct quality deficiencies, Campbell stated. You’ll need to show surveyors that your QAPI committee:
- systematically investigates and analyzes concerns and adverse events;
- identifies deviations from standards; and
- addresses issues with corrective actions and monitors for effectiveness.
Go Beyond the CEPs
No reprieve: Always keep in mind that the CEPs—although seemingly exhaustive—aren’t the limit of a surveyor’s scope. Expect the surveyor to evaluate an area of concern, even if there isn’t a specific related CEP, Campbell warned.
Bottom line: The new QAPI regulations and added CEPs aim to help you create a proactive, preventive, and less-institutional culture in your nursing facility, Bowman stressed. Instead of dreading your QAPI compliance responsibilities, try to leverage your proactive QAPI culture to your full advantage.