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The Correlation Between QAPI and the Facility Assessment

October 11, 2017
Compliance By Emile LeDoux, Senior Consultant

On November 28, 2017, phase two of the Centers for Medicare & Medicaid Services' (CMS) Requirements of Participation will go into effect. Included in phase two is the next step in implementing the Quality Assurance and Performance Improvement (QAPI) Plan, and the facility assessment. In this article, I will explain what is required of the QAPI program, and how it relates to the facility assessment.

The QAPI program replaces the previous quality assurance program, allowing facilities to use a unified program to focus on person-centered care. QAPI programs aid facilities in identifying areas of improvement and developing a plan to monitor and assess changes. The goal is to establish a program that improves the quality of life for residents while reducing facility deficiencies.

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The 3 Phases of QAPI Implementation

Phase 1: QAA committee

On November 28, 2016, all nursing facilities were to have established a Quality Assurance and Assessment (QAA) committee, meeting at least quarterly. The QAA committee should consist of the Director of Nursing, the Medical Director and three additional staff members (one of which must be the administrator, owner, board member or other individual in a leadership role). The role of the QAA committee is to steer the facility in which QAA items are necessary and to establish plans to address each item.

Phase 2: QAPI Plan

On November 28, 2017, each facility must have a written QAPI plan. State agencies will review the plans during the facility’s annual survey or during any state agency visit. The QAPI plan must outline the facility’s process for identifying and correcting quality issues. The facility will also be required to share their monitoring documentation. Furthermore, the QAPI plan must show how the facility plans to monitor progress, and it must incorporate input from residents and staff.

The QAA committee may use various sources of information for developing the QAPI process, such as resident satisfaction surveys, inspection results, medication audits, care planning audits, resident council, rehospitalization rates, staff turnover, falls, and food satisfaction surveys—just to name a few. The QAPI plan must reflect how often data is to be gathered, what benchmarks have been established, who will analyze the information, how frequently the information is to be analyzed, how the results will be communicated, and who the results will be shared with and how frequently.

The collected data will be used to identify Performance Improvement Projects (PIPs). The goal in identifying PIPs is to take a proactive approach to improvement. The facility must consider information from residents, families, staff and volunteers. Before PIPs are initiated, a full investigation should be conducted in order to identify the root cause of any issue.

The QAPI program, much like the facility assessment, will require facilities to review each of their service offerings. While conducting the assessment, the facility will need to use the QAPI program to assure that all risks have been assessed. Anytime adjustments are made to the facility assessment based on a change of service, the QAPI program must be updated as well. The facility assessment and the QAPI program parallel each other. What is needed to determine the risk and equipment assessment, for the facility assessment, will be found in the data collected through the QAPI Plan. The QAPI program should also include information regarding the infection control plan, fire drills and facility training which will be essential for creating an accurate and efficient facility assessment. The facility assessment, itself, is another data source for the QAPI program.

Phase 3: Full Implementation of QAPI program

On November 28, 2019, facilities will be expected to have their QAPI programs fully implemented with participation from an Infection Preventionist.

A QAPI program will only be effective if it receives support from senior leaders. The program is designed to be ongoing—identifying issues in operations while developing analysis and procedures to correct the issues. Benchmarks must be adjusted when positive progress has been made to push the program forward. A properly executed program will consist of employees from each department, residents, families, volunteers and senior leaders/owners.

Still feeling lost? Contact us for additional help or feel free to download our infographic titled “When Quality Improvement Doesn't Improve Quality.”


When Quality Improvement Doesn't Improve Quality Infographic