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Ftag of the Week – F865 QAPI Program/Plan, Disclosure/Good Faith Attempt (Part 2)

This week on the CMSCG Blog we are continuing our “Ftag of the Week” series on QAPI with Part 2 of F865 QAPI Program/Plan, Disclosure/Good Faith Attempt. In last week’s post, we reviewed the scope and design of a QAPI Program, the regulatory expectation that QAPI is continuous and ongoing, and also reviewed what will happen during survey related to QAPI. So, how does a facility ensure that all these things are happening and make proactive attempts to correct identified issues? Let’s find out.

Governance and Leadership

The governing body and/or executive leadership team are responsible for the facility’s QAPI program (view CMSCG’s Ftag of the Week on F837 Governing Body here). They are responsible for ensuring that the QAPI Program:

  • Is on-going, defined, implemented, maintained and addressed identified priorities
  • Does not encounter issues during leadership/staffing transitions
  • Has adequate resources (staff time/equipment/technical training)
  • Identifies and prioritizes issues and opportunities that reflect the facility’s process, functions and services provided to residents. This should be based on performance indicator data, resident input, staff input and other data sources available.
  • Has clearly set expectations regarding safety, quality, rights, choices and respect
  • Addresses gaps in systems through corrective actions that are evaluated for effectiveness

Good Faith Attempts

The regulation at F865 clearly discusses the idea of “good faith attempts to correct.” The Interpretive Guidance (IG) states that if a facility has identified and made a good faith attempt (through its QAA Committee) to correct an issue that has been identified by surveyors on the current survey, the facility will not be cited for QAA. However, the facility can still be cited under other relevant tags. The expectation is that the surveyor will determine if:

  • The facility became aware of the issue as soon as it should have
  • The issue was one the facility should have been tracking because it was high-risk/ high-volume / problem-prone
  • There was a negative outcome to a resident that should have alerted the facility to the issue
  • There has been sufficient time to address the issue by implementing changes and evaluating their effectiveness
  • The efforts made show an honest, diligent attempt to correct the issue

Other Things to be Aware of

  • Surveyors can only require a facility to disclose QAA Committee records if they are used to determine the extent to which the facility is compliant with the QAA provisions.
  • If documents contain information necessary to determine compliance with QAA or QAPI regulations, the facility must allow the surveyors to review and copy them.
  • Information from these records will not be used to cite new issues or expand the scope/severity of issues the surveyors have already identified. (This is why the QAPI/QAA review occurs towards the end of survey during the LTCSP.)
  • Reports and logs such as Incident/Accident reports, wound logs and other records used to track adverse events are not protected from disclosure.
  • If a facility refuses to provide evidence of compliance with QAA, the IG is very clear – the facility will be cited for noncompliance at F865, will be required to submit a Plan of Correction, and may be penalized with enforcement remedies that can include termination of the provider agreement. This is because the QAA Committee’s records may be needed to determine a facility’s compliance with Medicare requirements at 483.75, and access is denied to surveyors, this creates a risk of terminating the provider agreement.

In closing, if you have not wrapped your arms around the need to be compliant with all aspects of this regulation put some time aside for you and your team to review your QAPI Program / Plan and how you can demonstrate compliance.

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