This week’s Ftag of the Week is F868 QAA Committee. This regulation has some new additions effective Phase 3 (November 28, 2019) and a good deal of Interpretive Guidance added when the RoPs were updated, so let’s take a look at what is required from providers.
Each nursing home must have a Quality Assessment and Assurance Committee that reports to the facility’s Governing Body. The QAA Committee must meet at least quarterly and be comprised of the Director of Nursing, the Medical Director (or designee) and three additional members of the facility. One of these three members must be the Administrator, the owner, a Board Member or someone else who holds a leadership role. Beginning in Phase 3, the facility’s Infection Preventionist must be part of the QAA Committee.
Responsibilities of the QAA Committee
The QAA Committee is responsible for identifying and responding to quality deficiencies that are identified in the facility. It is also responsible for reporting to the Governing Body regarding the implementation of the QAPI Program. Related to QAPI, the QAA Committee is also responsible for identifying which QAA activities, including Performance Improvement Projects (PIPs) will be conducted. As we also discussed in prior Ftag of the Week posts, the QAA Committee must also develop and implement corrective actions for an identified issue and conduct monitoring to ensure goals are reached or revisions are made to corrective actions (if needed).
The QAA Committee must meet at least quarterly, and more often as needed to fulfill its responsibilities when quality issues have been identified that need to be corrected.
Responsibilities of the Medical Director
The Interpretive Guidance (IG) has been expanded significantly to outline the requirements of the Medical Director’s participation on the QAA Committee. The Medical Director is required to participate on the Committee since his/her responsibility is for the overall medical care being provided by the facility and for ensuring that resident care policies are implemented appropriately. There needs to be evidence that the Medical Director has participated “meaningfully,” and according to the IG, this can include trend reporting related to medication regimen reviews and other medical oversight activities.
If the Medical Director chooses to use a designee, that person may not be someone who is already a member of the QAA Committee, and he/she must be familiar with the facility’s P&Ps and practices in order to be able to provide value to the Committee. If the Medical Director utilizes a designee, there needs to be evidence that the designee has provided information on the meeting to the Medical Director. The Medical Director must acknowledge receipt of this information. Remember there are options for the Medical Director’s participation in scheduled meeting, including via video or teleconferencing. When remote participation is done, a facility needs to ensure that there is documented evidence of the Medical Director’s participation included in the attendance record.
On survey, before the QAPI Plan/ QAA review is conducted, surveyors will have identified and validated the presence of systemic issues in the facility, including repeat deficient practices and issues identified on survey that could be cited at a scope/severity of E or above. Your biggest fear should be that there is a quality issue/deficient practice that your QAA Committee is unaware of being identified during survey. There needs to be reliable communication and reporting systems established on how issues/concerns are brought to the attention of this committee and addressed. Such systems will help to avoid finding yourself responding to citations included on the CMS-2567 with a Plan of Correction.
CMS Compliance Group’s Quality Assurance and Performance Improvement regulatory group Ftag review includes these other Ftags:
- Ftag of the Week – F865 QAPI Program/Plan, Disclosure/Good Faith Attempt (Part 1)
- Ftag of the Week – F865 QAPI Program/Plan, Disclosure/Good Faith Attempt (Part 2)
- Ftag of the Week – F866 QAPI/QAA Data Collection and Monitoring
- Ftag of the Week – F867 QAPI/QAA Improvement Activities
Is your facility’s QAPI Program still a work in progress? CMS Compliance Group can help – learn more about our services for nursing homes here. Please email firstname.lastname@example.org to discuss how we can work together to help your organization implement a successful Quality Assurance and Performance Improvement Program ahead of Phase 3.