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Fundamentals of CMS Updates to Appendix PP of the State Operations Manual: Quality Assurance and Performance Improvement

F865: QAPI Program/Plan, Disclosure/Good Faith Attempt

Noncompliance at deficiency tag F865 will be cited if surveyors find that a facility has not implemented and/or maintained a comprehensive QAPI program that addresses all the care and unique services a facility provides.

The SOM Revisions to F865 Provide Guidance Regarding a Facility's Obligation to Document and Maintain Ongoing QAPI Programs and Disclose Relevant Information Upon Request

The new SOM guidance directs surveyors to request documentation of a facility's ongoing QAPI program's implementation and compliance with the Requirements of Participation. Quality Assurance and Performance Improvement (QAPI) includes the coordinated application of Quality Assurance (QA) and Performance Improvement (PI). The facility's Governing Body is responsible for overseeing the QAPI program, and surveyors are instructed to request evidence of the facility's ongoing QAPI program at the end of the survey to ensure that concerns identified by the survey team are independent of the QAPI/QAA (Quality Assessment and Assurance) review.

Upon request, a facility must disclose its QAPI/QAA information to the state survey agency and/or CMS to the extent the information is necessary to demonstrate the facility's compliance with the Requirements of Participation. Refusal by a facility to produce evidence of compliance with QAPI/QAA will lead to citation of noncompliance with F865, requiring a plan of correction, and possible imposition of enforcement remedies up to and including termination of the facility's provider agreement.

Key Takeaways

A facility must present its QAPI plan to the state survey agency/federal surveyors no later than October 24, 2023, and present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements upon request. Documents of the QAA committee are afforded very little protection from disclosure. In fact, a facility must allow a surveyor to review and copy documents generated by the QAA committee, such as minutes, internal papers, or conclusions if those documents contain the evidence necessary to determine compliance with QAPI/QAA regulations.

F867: QAPI/QAA Improvement Activities

Noncompliance at deficiency tag F867 will be cited if surveyors find that a facility failed to obtain feedback, use data, and/or take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that affect quality of care, quality of life, and resident safety.

SOM Revisions to F867 Provide Guidance on Obtaining Feedback, Monitoring Data, and Implementing Corrective Actions to Improve Performance

The new SOM update combines F866 and F867 and requires a facility to develop and implement systems that ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice. This is accomplished, in part, by identifying, collecting, analyzing, and monitoring data that reflects the functions of each department and outcomes to residents. Feedback is one of the many data sources a facility must collect and facilities are required to obtain feedback from direct care staff, other staff, residents, and resident representatives. Effective feedback also includes methods for providing feedback to direct care staff, other staff, residents, and representatives; facilities are instructed to choose the best mechanism for feedback to support their QAPI programs.

The SOM update further requires facilities to have policies and procedures in place to address data collection, monitoring performance indicators, and implement actions intended to improve performance. Noncompliance with F867 includes failure to track medical errors and adverse events, analyze their causes, and implement preventive actions and mechanisms, such as educating staff and/or residents. A facility is also now required to conduct at least one performance improvement project annually.

Key Takeaways

A facility must develop and maintain a robust QAA committee that is responsible for identifying deficiencies, reviewing, and analyzing data and developing and implementing appropriate plans of action. Each facility must then conduct at least one improvement project annually that focuses on high-risk or problem-prone areas, identified by the facility through data collection and analysis.

F868: Quality Assessment and Assurance (QAA) Committee

Noncompliance at deficiency tag F868 will be cited for concerns related to the composition of the QAA committee, frequency of meetings and reporting to the governing body.

SOM Revisions to F868 Provide Guidance on the Composition of the QAA, Frequency of Meetings and Reporting Requirements

QAA Committee responsibilities include identifying and responding to quality deficiencies throughout out the facility, and oversight of the QAPI program when fully implemented. The QAA Committee is also tasked with developing, implementing, and revising corrective action when necessary, and monitoring to ensure performance goals and targets are achieved. The new SOM guidance states that a QAA Committee must now include the Infection Preventionist (IP), and that the QAA Committee is responsible for reporting its activities, including implementation of the QAPI program, to the facility's governing body. QAA Committee meetings must be held at least quarterly.

Key Takeaways

The IP must be a participant on the facility's QAA Committee and report to the committee on a regular basis about the IPCP and incidents identified under the program. The QAA Committee must also report on its activities to the facility's governing body.

For specific guidance or more information about this alert, please contact Howard Sollins, Stefanie Doyle, or any other member of Baker Donelson's Long Term Care Team.

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