Ftag of the Week – F944 QAPI Training

This week’s “Ftag of the Week” on the CMSCG Blog is another Phase 3 requirement, F944 QAPI Training. Just like with last week’s post regarding mandatory Infection Control Training, it’s likely that most providers already have training for their Quality Assurance and Performance Improvement (QAPI) Program in place, but now with the draft guidance in Appendix PP released, we know exactly what’s expected. Don’t forget that with the updated guidance, the Phase 3 requirement F855 QAPI/QAA Data Collection and Monitoring F-tag was removed and the guidance was moved to F867 QAPI/QAA Improvement Activities, so if you haven’t looked at the regulatory references in your plan, now is a good time to do so.

Let’s look at what’s required for QAPI training under the updated regs.

QAPI Program Training

Nursing homes are expected to have mandatory training for all staff on the facility’s QAPI Program. “All staff” for the purposes of this regulation includes all new and existing employees, regardless of their position being direct care or indirect care, as well as contract staff and volunteers, consistent with their roles. With the influx of agency staff use, how sure are you that these staff members – or most staff really – could tell a surveyor about what the facility’s current QAPI Program goals are or how new ideas should be brought to the QAA Committee?  A real concern, as well, is how are you including all levels of staff in the QAPI process. Hopefully, you are well beyond the notion that only Department Heads are involved and have responsibilities related to QAPI.

F944 requires that QAPI Training includes the goals of the program and other portions of the program, including explaining how the facility intends to implement its program. Staff should understand their role in the overall Program, including how they can communicate opportunities for improvement and concerns/problems to the QAA Committee to potentially be included in QAPI. As with other training requirements, the expectation is that if the program or its goals are changed or updated, staff likely should be trained on the updates.

CMSCG Survey Tip

Surveyors are directed to identify how a provider determines when its training content needs updating to ensure it is consistent with professional standards and guidelines. When was the last time your training content was updated, and a revised version provided to existing staff? While you are up to it, have you considered including any new care/services being offered by the facility (Facility Assessment information) that warrants monitoring or a PIP?

One final note – make sure you are keeping track of who has received the training. The updated guidance notes that this tag can be cited if there is deficient staff training identified – but no outcome deficiency has to be identified for it to be cited. Deficiencies related to the QAPI Program or QAA Committee will be investigated under the QAPI F-tags. Who would have ever thought that the current emphasis on QAPI would be at the level that it is going to be so very soon? If you think about it, this is the natural progression of the overall concept that providers have an obligation to provide quality care and services to their resident population. It is going to be a step for some providers to take a long, hard look at what is going badly and figure out how to implement an improvement plan. It is time to think about this – how could every area you monitor be 100% compliant? If they all are at 100%, you are looking at the wrong things.

It is time to think about this – how could every area you monitor be 100% compliant? If they all are at 100%, you are looking at the wrong things.

Linda Elizaitis, CMS Compliance Group President

There will be no Ftag of the Week next week, ahead of Labor Day weekend. See you in September!

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