Ftag of the Week – F866 QAPI/QAA Data Collection and Monitoring

This week’s “Ftag of the Week” on the CMSCG Blog is F866 QAPI/QAA Program Feedback, Data Collection and Monitoring, which is part of the Quality Assurance and Performance Improvement Regulatory Group. This Ftag becomes effective in Phase 3 (November 28, 2019). F866 outlines a provider’s responsibilities for developing and implementing policies and procedures related to its QAPI program feedback, data collection systems and monitoring (§483.75(c)(1-4)).

Nursing homes must develop and implement written policies and procedures related to how feedback and data will be collected and monitored, including monitoring of adverse events. The P&Ps must include:

  • How the facility will maintain effective systems to obtain and use feedback/input provided by stakeholders including direct care and other staff and residents/representatives
  • How feedback will be utilized to identify problems that are high risk, high volume, problem-prone or present opportunities for improvement
  • How effective systems for identification, collection and use of data from all departments will be maintained and how this information will be used for developing and monitoring performance indicators. This information, per the regulation, includes the Facility Assessment.
  • How the facility will develop, monitor and evaluate performance indicators, including the methodology and frequency
  • How the effectiveness of the facility’s performance improvement activities will be monitored to ensure improvements are sustained
  • How the facility will monitor adverse events, including the systematic ways it will identify, track, report, investigate, analyze and use adverse event data, as well as how the facility will develop activities that will prevent adverse events in the future

QAPI requires proactivity from providers in order to develop a program that can systematically capture facility-specific data and ensure it is used for performance improvement activities related to identified problematic areas. In our last two Ftag of the Week posts, we looked at F865 to provide an overview of the QAPI Program requirements, and we will continue to examine the rest of the QAPI regulations in our next few posts.

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