Harmony Healthcare Blog

QAPI Program: Is Your Facility Prepared? (Part 1)

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Thu, Feb 23, 2017
Kris Mastrangelo, OTR/L, LNHA, MBA
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C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


Quality-Assurance-.jpegWhat are we seeing this past week?  An intense amount of focus on preparedness for Quality Assurance and Performance Improvement (QAPI) Program Development. 

QAPI is an ongoing, systematic, comprehensive and data driven system for quality improvement that merges Quality Assessment and Performance Improvement.  Most Skilled Nursing Faculties focus on the identification, prevention, and quick fixes to mitigate risk areas.  However, the approach described focuses purely on performance improvement

An effective QAPI Program is focused on creating effective systems to strategically manage all aspects of health care quality.  QAPI strives to dig deep into the root cause of an issue and seek a path for improvement for both internal and external customers. 

The QAPI Program is not just designed to address current problems in the facility.  Rather, it is geared towards a proactive management of quality care.  QAPI challenges facilities to consider areas where they are doing well, and strive for excellence. 

For over 20 years, the existing QAA regulation for Long Term Care facilities has specified very minimal requirements.  The requirement stated that that each nursing home will have a QAA committee with certain members, and at least three other members of the facility’s staff that meet at least quarterly.  This team is charged with the task of “developing and implementing appropriate plans of action to correct identified quality deficiencies”.  With the advent of the Requirements of Participation in October 2016, a timeline for implementation has been established. 

Free RUG Analysis - Compare your facility's utilization with current national CMS dataQuality Assurance and Performance Improvement (QAPI)” (§ 483.75) per the Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities; Final Rule (10/4/16) States: 

“In accordance with the statute, we require all LTC facilities to develop, implement, and maintain an effective comprehensive, data-driven QAPI program that focuses on systems of care, outcomes of care and quality of life.” 

483.75 Quality Assurance and Performance Improvement will be implemented in Phase 3 with the following exceptions

  • Phase 1 (11/28/16) 
    • The facility must maintain a Quality Assessment and Assurance (QA&A) committee consisting of the Director of Nursing, Physician, and three other members of the facility staff. The QA&A Committee must:
      • Meet at least quarterly
      • Identify quality deficiencies and develop and implement plans of action to correct deficiencies.
      • Formalized Governing Body, or designated persons functioning as a governing body, will guarantee that the QAPI program is defined, implemented, maintained and addresses identified priorities. 
  • Phase 2 (11/28/17)
    • Section 483.75(a)(2) Initial QAPI Plan must be provided to State Agency Surveyor at annual survey —Implemented in Phase 2. 
  • Phase 3 (11/28/19)
    • Mandatory addition of Infection Control and Prevention Officer to committee membership.

Need additional training or a better understanding of QAPI?  Join us for our upcoming QAPI Certification Courses (CHHi-QAPI).  Click here to see the dates and locations.


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Topics: QAPI

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