Long-Term Care Survey Alert

Feds aim for better dementia care through performance improvement.

Better dementia care may be a common goal among long-term care providers, but there’s a new twist to the perennial cause that you shouldn’t miss: the feds — and many of your competitors — are starting to focus not only on better care but also on improving the methods used to realize better care. 

The new focus on process coincides with a prolonged push by the Centers for Medicare and Medicaid Services (CMS) to bring its Quality Assurance and Performance Improvement (QAPI) initiative to nursing homes. 

Background: The Affordable Care Act called on CMS to rollout QAPI for nursing facilities, calling for a March 2013 program implementation. More than two years later, there’s still no published regulation, but that hasn’t stopped the agency from promoting the program. A website has been in place since 2013, and most recently, on March 10, CMS offered an MLN Connects National Provider Call outreach session titled “National Partnership to Improve Dementia Care in Nursing Homes & Quality Assurance and Performance Improvement.”

Nursing homes have long been motivated to set quality thresholds to fare well at survey time, but the feds and other stakeholders are nudging providers to adopt a different mindset: creating and achieving standards that go beyond current regulatory compliance. 

Watch Out For Impact On Survey Scores

The agency’s focus on QAPI as it relates to dementia care suggests that the program will eventually come to bear on the survey process, insiders say.

The agency aims to “embed principles for reducing adverse events in the roll out of QAPI,” revealed CMS’s Debra Lyons during the March outreach session. CMS also announced that they plan to look at providers’ systems for “identifying, tracking, correcting, and evaluating adverse events.”

Clueless: Still, with no final — or even proposed — rule to date, providers are left waiting for clues regarding surveyors’ roles in evaluating nursing homes’ QAPI programs as well as how this oversight and the program in general will relate to current nursing home survey requirements.

The feds have provided few insights, except indications that QAPI oversight is on the horizon. Currently, nursing homes are bound by Quality Assessment and Assurance (QAA) provision at 42 CFR, Part 483.75(o), which outlines the QAA committee composition and frequency of meetings in nursing facilities; it also requires facilities to develop and implement plans of action to correct any identified quality deficiencies. Absent from that provision, however, are any details as to the means and methods taken to implement the QAA regulations.

Expect More Oversight

With QAPI, there are indications that considerably more oversight is pending. CMS points out, for example, that it 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.”

According to CMS, the new requirement “significantly expands the level and scope of required QAPI activities to ensure that facilities continuously identify and correct quality deficiencies as well as sustain performance improvement.”

QAPI is more comprehensive than simple quality assessment as it exists in nursing home regulation today, says Lyons, adding that QAPI “can take nursing homes to a new level.”

Start ramping up: With all of that in mind, it’s surely prudent for providers to start ramping up with QAPI programs, even without the benefit of published regulations.

“We do think that now is the time to get started with laying the foundation of QAPI,” urges Lyon.

Although nursing homes must continue work to ensure the existing Quality Assessment and Assurance regulation (F-520) is met, they can look to QAPI materials to guide the work of the QAA committee.

Kickoff from here: Begin by reviewing the QAPI resources available at the CMS website for nursing home QAPI (see Resources), but you should also look closely at the National Partnership initiative, suggests Alice Bonner, PhD, RN, the former director of the skilled nursing division at CMS and now professor at Northeastern University.

Why? Attending to the goals set forth in Advancing Excellence goals will help nursing homes with QAPI.

Team effort: With a QAPI approach, staff at all levels of the organization should help “identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions,” outlines Lyons.

Bonner calls for strong nursing leadership in the process. Speaking recently at a meeting of the National Association Directors of Nursing Administration in Long Term Care conference in Anaheim, CA, she noted that QAPI can help address staffing problems that often contribute to less than ideal outcomes.

For example, QAPI can help nurse leaders learn — and teach others — effective ways to find the staff you need. The staffing mindset might change, for example, from an ad hoc system of keeping positions filled to an attitude of “growing” your own people, she explained.