CMS Final Rule – §483.75 Quality Assurance and Performance Improvement (QAPI)

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Implementation Date:

Phase 3 – November 28, 2019 – with the following exceptions
Phase 2 – November 28, 2017 – §483.75(a)(2) Initial QAPI Plan must be provided to State Agency Surveyor at annual survey
Phase 1 – November 28, 2016 -  §483.75(h) and (i) – Disclosure of information and Sanctions
Phase 1 – November 28, 2016 – §483.75(g)(1) – QAA Committee – all will be implemented in Phase 1 except subparagraph (iv), the addition of the ICPO, which will be implemented in
Phase 3, November 28, 2019

Current regulation §483.75(o) contains the provisions regarding maintaining a QAA committee. Most of the substance of this section has now been incorporated into a revised §483.75(g). The basics of §483.75(o) that remain in the revised section must be implemented, or remain implemented, by November 28, 2016. The only change to the makeup of the QAA committee is that by November 28, 2019, an infection control and prevention officer (ICPO) must be established and added to the committee.

While the facility’s QAPI plan does not have to be implemented until November 28, 2019, the plan must be developed and provided to the State Surveyor during the annual survey by November 28, 2017. The revised regulation outlines the development of the QAPI program, the requirements for the design and scope of that program, requirements for feedback, data systems and monitoring, the establishment of ways to conduct systematic analysis and action regarding QAPI developed data, the use of programs to address high-risk, high-volume and problem-prone areas, and the responsibilities of the Governing Body, or its equivalent, with regard to the QAPI program.

What then is required for the QAPI plan? Under §483.75(a), each facility must develop, implement and maintain an effective, comprehensive and data-driven QAPI program focusing on the indicators and outcomes of care and quality of life. The facility must maintain documentation regarding this program and how it meets these requirements. There is leeway given on what the documentation should include, but examples provided in the rule include identifying and investigating events and implementing action steps to correct the issue.

The QAPI program must (1) address all systems of care and management practices; (2) include clinical care, quality of life and resident choice; (3) utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes; and, (4) reflect the complexities, unique care and services the facility provides.

The facility must also develop new Policies and Procedures related to the QAPI plan. These Policies and Procedures must include systems to obtain and use feedback from direct care staff, other staff, residents and resident representatives that can be used to identify high risk, high volume or problem-prone issues and opportunities for improvement. They must also include Policies and Procedure for systems to identify, collect and use data from all departments to develop and monitor quality indicators, and for the development, monitoring and evaluation of performance indicators, including the methodology and frequency of this development, monitoring and evaluation. Finally, the facility must develop Policies and Procedures for adverse event monitoring.

Under §483.75(d), the facility must develop systems for performance improvement, and subsequently measure that improvement and ensure that the improvements are realized and sustained. The facility must develop Policies and Procedures to track these requirements.

Under §483.75(e), the facility must prioritize the high-risk, high-volume and problem-prone areas through its performance improvement activities. This would include tracking all medical errors and adverse resident events. The facility must also implement distinct performance improvement projects which must include, at least annually, a project focusing on the high-risk and problem-prone areas.

§483.75(g) outlines the responsibilities of the Governing Body and/or executive leadership with regard to the QAPI program. The QAA committee must report to the Governing Body and/or executive leadership about its activities. The QAA committee must meet at least quarterly to evaluate the QAPI program, develop and implement plans of actions to correct identified quality deficiencies, and review and analyze data generated under the QAPI program to make improvements.

Again, while the QAPI plan does not have to be implemented until November 28, 2019, it must be presented to the State during the annual survey by November 28, 2017. Therefore, time is running on making sure your facility is compliant.

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By Jonathan W. McCrary

Jonathan McCrary

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