MDS Alert

Make sure you have these policies and procedures down pat before Phase III of ROP hits in November.

Phase III of the Requirements of Participation (ROP) will go into effect Nov. 28, 2019. Learn which deficiencies are associated with the Quality Assurance and Performance Improvement (QAPI) regulatory group so you’re prepared for the changes, as well as surveyors’ visits.

There are four Ftags associated with the QAPI program: F865, F866, F867, and F868. They cover deficiencies related to disclosure and good faith attempt, and QAPI and Quality Assessment Assurance (QAA) data collection and monitoring, as well as improvement activities.

Know that F865 Provides the ‘Meat’

The QAPI program has been implemented in part over the last couple years. It — and its correlating regulations — are designed to ensure that facilities develop, implement, and maintain an effective, comprehensive, and data-driven program that focuses on care outcome indicators as well as quality of life, says Linda Elizaitis, Rn, RAC-CT, BS, CIC, president of CMS Compliance Group in Melville, New York.

To avoid being cited for F865, a facility’s QAPI program must address “… all systems of care and management practices, include clinical care, quality of life and resident choice, reflect the complexities, unique care/services being provided and utilize best available evidence to define and measure indicators of quality and the facility’s goals,” she says. The goals should demonstrably effect residents’ desired outcomes, she adds.

Surveyors will be looking for documentation and evidence that facilities’ QAPI programs are ongoing, she says. They will be particularly focused on evaluating the systems and reports that identify, report, investigate, analyze, and work to prevent adverse events, as well as looking for documentation that proves that a facility is developing, implementing, and evaluating corrective actions or performance improvement activities (PIPs), she explains. Facilities are expected to provide this information whenever surveyors ask.

“Under the LTCSP, the QAPI Plan/QAA review task is expected to occur towards the end of the survey, according to the Interpretive Guidance (IG),” Elizaitis says. “Surveyors should have completed their investigations into all the other requirements to ensure that these findings are independent of what is reviewed in the QAPI Plan/QAA review.”

Elizaitis recommends reviewing your QAPI plan to make sure that it covers these bases, and to ensure that there are systems in place to show how your facility identifies and corrects quality deficiencies.

“Once you finish your review, ask yourself if your QAPI Plan is robust enough to be scrutinized and if your QAPI Committee is ‘looking at’ issues that really affect your resident population,” she says.

The QAPI committee is comprised of the governing body/executive leadership team. Elizaitis explains that they’re responsible for making sure the QAPI program:

• Is ongoing, defined, implemented, and maintained, and addressed identified priorities;
• Does not encounter issues during leadership or staffing transitions;
• Has adequate resources, as far as staff time, equipment, or technical training;
• Identifies and prioritizes issues and opportunities that reflect the facility’s process, functions, and services provided to residents (this should be data-based, reflecting performance indicator data, resident input, and staff input);
• Has clearly set expectations regarding safety, quality, rights, choices, and respect; and
• Addresses gaps in systems through corrective actions that are also evaluated for effectiveness.

Surveyors know that problems arise, and are focused on making sure that facilities are aware of issues and moving to correct and/or prevent them.

Other QAPI-Related Ftags Focus on Policies, Procedures

Sometimes it’s easiest to understand regulations by focusing on the penalties — knowing what can get you in trouble illuminates the parameters by which you must abide. For the rest of the QAPI-associated Ftags, surveyors provide specific guidance on how your facility’s systems should work in terms of collecting relevant data and zeroing-in on — and correcting, when necessary — any issues.

Remember, the goal is, ostensibly, to avoid issues, but surveyors are mostly looking to make sure that residents are safe and that your facility can adeptly identify problems and has plans and programs in place to cut down on or prevent similar issues in the future.

“QAPI requires proactivity from providers in order to develop a program that can systematically capture facility-specific data and ensure it is used for performance improvement activities related to identified problematic areas,” Elizaitis says.

F867 can be cited if a facility isn’t maintaining systems surrounding data collection for obtaining and using feedback by stakeholders, direct care and other staff, and residents or their representatives, Elizaitis explains. Facilities must also show how they utilize the feedback to identify problems and illuminate areas for both immediate and sustained improvement.

Make sure you know how your facility is maintaining effective systems surrounding the identification, collection, and use of data — from all departments — as well as how the data will be used for developing and monitoring performance indicators, and the methodology and frequency involved. “This information, per the regulation, includes the Facility Assessment,” Elizaitis says.

Know What Phase III Brings

If your QAPI program isn’t already prioritizing performance improvement projects (PIPs) or activities, make sure you have a plan to make adjustments soon.

“Performance improvement activities must track medical errors and adverse resident events. The causes of these issues must be analyzed, and preventive actions put into place to prevent recurrence. This includes ‘feedback and learning throughout the facility’ per the Interpretive Guidance (IG), so there is a staff education component included here as well,” Elizaitis says.

Note: Your facility must determine one PIP, annually, that focuses on a facility-identified issue — identified through data collection and analysis —that is high-risk or problem-prone.

There’s also an intensified focus on the responsibilities and accountability of the medical director, especially within the QAA Committee.

The medical director must participate in the QAA committee because she’s responsible for the overall medical care the facility provides, as well as making sure that resident care policies are implemented appropriately, Elizaitis explains.

“There needs to be evidence that the Medical Director has participated ‘meaningfully,’ and according to the IG, this can include trend reporting related to medication regimen reviews and other medical oversight activities,” she says.

In terms of upcoming surveys, beware of surveyors sussing out issues within the facility that the QAA Committee hasn’t already identified. Elizaitis says this should be your biggest fear.

“There needs to be reliable communication and reporting systems established on how issues/concerns are brought to the attention of this committee and addressed,” she says.