MDS Alert

Fully understand these expert tips so you can play by surveyors’ rules.

If a facility has identified an issue under the Quality Assurance and Performance Improvement (QAPI) umbrella and made a good-faith attempt to correct it, surveyors won’t give citations relating to Quality Assessment Assurance. However, surveyors can still cite a facility under other relevant tags.

Linda elizaitis, RN, RAC-CT, BS, CIC, president of CMS Compliance Group in Melville, New York, explains how surveyors can approach information related to facilities’ QAPI programs and plans. She says that the expectation is that the surveyor will determine whether:

• the facility became aware of the issue as soon as it should have;
• the issue was one the facility should have been tracking because it was high-risk or high-volume or problem-prone;
• there was a negative outcome to a resident that should have alerted the facility to the issue;
• there has been sufficient time to address the issue by implementing changes and evaluating their effectiveness; and
• the efforts made show an honest, diligent attempt to correct the issue.

“Surveyors can only require a facility to disclose QAA Committee records if they are used to determine the extent to which the facility is compliant with the QAA provisions,” she says.

However, there are some important caveats that you should know.

Your facility must allow the surveyors to review and copy documents that contain information necessary to determine compliance with QAA or QAPI regulations, she notes.

However, “information from these records will not be used to cite new issues or expand the scope/severity of issues the surveyors have already identified. This is why the QAPI/QAA review occurs toward the end of survey during the LTCSP,” she says.

Other reports and logs, including incident or accident reports, wound logs, and other records used to track adverse events are not protected from disclosure.

Refusing to provide evidence of compliance with QAA can lead to some serious penalties. Beyond citation of F865, the facility will be required to submit a Plan of Correction, and may face enforcement remedies that can include termination of the provider agreement, Elizaitis explains.

Important: Information within the QAA Committee’s records may be necessary to determine whether a facility is compliant with Medicare requirements surrounding § 483.75 Quality assurance and performance improvement, and denying access to surveyors creates a risk of terminating the provider agreement.