This week’s “Ftag of the Week” on the CMSCG Blog begins our look at the Quality Assurance and Performance Improvement regulatory group, which is comprised of 4 Ftags. F865 QAPI Program/Plan, Disclosure/ Good Faith Attempt is a large regulation that was partially effective in Phase 2, but will be fully implemented in Phase 3 – November 28, 2019 – so it’s important to review ahead of this year’s effective date.
QAPI Program Scope & Design
The regulation at F865 requires that facilities develop, implement and maintain and effective, comprehensive and data-driven QAPI Program that focuses on indicators of care outcomes and quality of life. Each facility’s QAPI Program must address the full scope of care and services being provided. The QAPI Program must address all systems of care and management practices, include clinical care, quality of life and resident choice, reflect the complexities, unique care/services being provided and utilize best available evidence to define and measure indicators of quality and the facility’s goals. These indicators and goals must be predictive of desired outcomes for residents.
Ongoing QAPI Efforts
Facilities are required to maintain documentation and be able to demonstrate evidence that their QAPI Programs are ongoing. The regulation at F865 states that this may be shown through systems and reports that demonstrate:
- Systematic identification, reporting, investigation, analysis and prevention of adverse events
- Documentation that demonstrates the development, implementation and evaluation of corrective actions or performance improvement activities (PIPs)
What to Expect on Survey
Effective with Phase 2 of the RoPs (November 28, 2017), facilities were required to present their written QAPI plans to surveyors. The expectation is that facilities will present their QAPI plans to surveyors during recertification surveys, when requested during any other survey type, or when the Centers for Medicare & Medicaid Services (CMS) requests it at any time. Facilities are expected to present documentation/evidence that their QAPI Program is ongoing whenever surveyors or CMS requests this information.
Under the LTCSP, the QAPI/Plan QAA review task is expected to occur towards the end of the survey, according to the Interpretive Guidance (IG). Surveyors should have completed their investigations into all the other requirements to ensure that these findings are independent of what is reviewed in the QAPI Plan/QAA review. This helps to ensure that QAA Committee documents are not used by surveyors to identify additional concerns and to encourage facilities to feel as though they can openly conduct QA investigations and PI efforts without worrying it will have a negative outcome.
You might want to consider reviewing your QAPI Plan to ensure that it includes everything that it should, including how you identify and correct quality deficiencies. Guidance related to the QAPI Plan, per CMS, notes that key components to the process should include: “tracking and measuring performance, establishing goals and thresholds for performance measurement, identifying and prioritizing quality deficiencies, systematically analyzing underlying causes of system quality deficiencies, developing and implementing corrective action or performance improvement activities and monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed.” Once you finish your review, ask yourself if your QAPI Plan is robust enough to be scrutinized and if your QAPI Committee is “looking at” issues that really affect your resident population.
In Part 2 of our Ftag of the Week related to F865, we will look at who is responsible for the QAPI program and what type of QAA information needs to be provided to surveyors, as well as defining “good faith attempts” to correct.