QAPI Audit

As SNF is required by CMS to have a structured QAPI plan as part of the facility's quality assurance efforts.

QAPI, the facility will use data to identify new or emerging performance improvement opportunities in order to elevate or maintain program performance. QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions. When root causes are investigated and action plans are developed to address these unique issues, sustainable change is less likely an anomaly - but a standard of practice. The existing Quality Assessment and Assurance (QAA) provision at 42 CFR, Part 483.75(o) specifies the QAA committee composition and frequency of meetings in nursing facilities and requires facilities to develop and implement appropriate plans of action to correct identified quality deficiencies. This provision provides a rule but not the details as to the means and methods taken to implement the QAA regulations. CMS is now reinforcing the critical importance of how nursing facilities establish and maintain accountability for QAPI processes in order to sustain quality of care and quality of life for nursing home residents.

How can Harmony Healthcare International (HHI) help?

Harmony (HHI) will lead the development, implementation, maintenance, and evaluation of effective process function as part of this engagement with (Name of Facility) through the following steps:

  • Develop QAPI committee with identification of committee chair and co-chair.
  • Develop QAPI committee charter including identification of Responsibility Assignment Matrix (RACI Matrix).
  • Identify specific initiatives to be addressed based on areas recognized during the facility systems review and gap analysis process performed earlier during the engagement.
  • Harmony (HHI) will review the facility's CASPER Report and Five Star Rating to select initiatives that align with current and future Value-Based Purchasing and Quality focused payment structures.
  • Monthly executive summary to the facility leadership focused on progress
  • Reports will be prepared independently by Harmony (HHI)

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