9/8/2017. Making the Connection: Linking the Facility Assessment and QAPI Plan. Cindy Mason VP Provider Services. Final Rule. Providigm, LLC,

Transcription

1 Making the Connection: Linking the Facility Assessment and QAPI Plan Cindy Mason VP Provider Services Final Rule Providigm, LLC,

2 Final Rule Effective Date These regulations are effective as of November 28, Phase 1 Phase 2 Phase 3 November 28, 2016 The regulations included in Phase 1 must be implemented by November 28, November 28, 2017 The regulations included in Phase 2 must be implemented by November 28, November 28, 2019 The regulations included in Phase 3 must be implemented by November 28, Administration Providigm, LLC,

3 Administration F Tags Administration Phases This section will be implemented in Phase 1 with the following exceptions: (d)(3) Governing body responsibility of QAPI program Implemented in Phase 3. (November 28, 2019) (e) Facility assessment Implemented in Phase 2. (November 28, 2017) Providigm, LLC,

4 Administration Administration A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. GUIDANCE Resources include but are not limited to a facility s operating budget, staff, supplies, or other services necessary to provide for the needs of residents. Administration PROCEDURES Cite this tag if the actions, inactions, or decisions in administering the facility contributed to deficient practice(s). The facility s administration is not limited to the administrator and may also include the facility s governing body, management company, and/or others identified by the facility as part of the facility administration. The investigation must demonstrate how the administration knew or should have known of the deficient practice and how the lack of administration involvement contributed to the deficient practice found. When citing this F835, it is not acceptable to simply reiterate the noncompliance from any other associated tags and then refer to this tag. Surveyors must document how the administration knew or should have known of the deficient practice and taken action(s) as appropriate. Providigm, LLC,

5 Administrator uses resources effectively and efficiently Resources include but are not limited to a facility s operating budget, staff, supplies, or other services necessary to provide for the needs of residents Reviews and revises assessment annually and as needed Documents corrective actions and monitors effectiveness Administrative Role in Facility Assessment and QAPI Assesses current and needed resources in Facility Assessment Communicates needed resources to board/governing body Resources include but are not limited to a facility s operating budget, staff, supplies, or other services necessary to provide for the needs of residents Identifies quality deficiencies related to inadequate resources Monitors data to identify quality deficiencies Obtains/supplies needed resources for resident population Governing Body DEFINITIONS (d) Governing body refers to individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility. Providigm, LLC,

6 Governing Body (d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and INTENT (d) This regulation is intended to ensure that the facility has an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility. Governing Body (d)(2) 2) The governing body appoints the administrator who is (i) Licensed by the State, where licensing is required; (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. 3) The governing body is responsible and accountable for the QAPI program, in accordance with (f). (Phase 3) Providigm, LLC,

7 Governing Body (d)(3) (d)(3) The governing body is responsible and accountable for the QAPI program, in accordance with (f). [ (d)(3) Governing body responsibility of QAPI program will be implemented beginning November 28, 2019 (Phase 3).] Governing Body GUIDANCE (d) The facility must determine: A process and frequency by which the administrator reports to the governing body, the method of communication between the administrator and the governing body including, how the governing body responds back to the administrator and what specific types of problems and information (i.e., survey results, allegations of abuse or neglect, complaints, etc.) are reported or not reported directly to the governing body; How the administrator is held accountable and reports information about the facility s management and operation (i.e., audits, budgets, staffing, supplies, etc.).; and How the administrator and the governing body are involved with the facility wide assessment in (e) Facility assessment at F838. Providigm, LLC,

8 Administration Facility Assessment Governing Body QAPI Program Resource Distribution Survey Procedures PROCEDURES (d) Request the names and contact information of the members of the governing body at the Entrance Conference. If there are concerns, conduct an interview with the administrator and if possible with one or more members of the governing body or designated person(s) functioning as the governing body. Providigm, LLC,

9 Administration: Facility Assessment Services Provided Determining Staffing Requirements Staff Competency Assessing Acuity and Diseases, Conditions, Disabilities Facility Assessment Facility Resources, Equipment, Technology Establishing QAPI Program Conducting Emergency Preparedness Providigm, LLC,

10 Facility Assessment INTENT (e) and Guidance The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require. The facility assessment will enable each nursing home to thoroughly assess the needs of its resident population and the required resources to provide the care and services the residents need. It should serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources, and may include the operating budget necessary to carry out facility functions. Facility Assessment GUIDANCE (e) A facility assessment may be similar to common business practices for strategic and capital budget planning. Strategic planning is an organization's process of defining its strategy, or direction, and making decisions on allocating its resources to pursue this strategy. However, while a facility may include input from its corporate organization, the facility assessment must be conducted at the facility level Providigm, LLC,

11 Facility Assessment GUIDANCE (e) To ensure the required thoroughness, individuals involved in the facility assessment should, at a minimum, include the administrator, a representative of the governing body, the medical director, and the director of nursing. The environmental operations manager, and other department heads (for example, the dietary manager, director of rehabilitation services, or other individuals including direct care staff should be involved as needed. Facility Assessment: Administration F (e) (e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Providigm, LLC,

12 Facility Assessment GUIDANCE (e) The facility must review and update this assessment annually or whenever there is, or the facility plans for, any change that would require a modification to any part of this assessment. For example, if the facility decides to admit residents with care needs who were previously not admitted, such as residents on ventilators or dialysis, the facility assessment must be reviewed and updated to address how the facility staff, resources, physical environment, etc., meet the needs of those residents and any areas requiring attention, such as any training or supplies required to provide care. Facility Assessment GUIDANCE (e) The assessment must include or address the facility s resources which include but are not limited to a facility s operating budget, supplies, equipment or other services necessary to provide for the needs of residents. Providigm, LLC,

13 Facility Assessment GUIDANCE (e) The assessment must include or address an evaluation of the facility s training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment should also include an evaluation of what policies and procedures may be required in the provision of care and that these meet current professional standards of practice. If there are any concerns regarding training refer to Training. Gap Analysis Current State Assessment Bridging the Gap Future State Needs and Vision Gap Identification Providigm, LLC,

14 Facility Assessment Referenced in Additional Regulatory Areas Behavioral Health Nursing Infection Control QAPI Training Requirements Staffing Administration Facility Assessment: Resident Population Providigm, LLC,

15 Facility Assessment (e)(1) Resident population The facility assessment must address or include: (1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. Resident Population GUIDANCE (e) An assessment of the resident population is the foundation of the facility assessment. It must include an evaluation of diseases, conditions, physical, functional or cognitive status, acuity of the resident population, and any other pertinent information about the residents that may affect and plan for the services the facility must provide (e.g., MDS data, Facility Characteristics report form CMS 672). The assessment of the resident population will also contribute to identifying the physical space, equipment, assisted technology, individual communication devices, or other material resources that are needed to provide the required care and services to residents. Providigm, LLC,

16 MDS Resident Population GUIDANCE (e) The regulation outlines that the individualized approach of the facility assessment is the foundation to determine staffing levels and competencies. Therefore, the facility assessment must include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident s needs. Providigm, LLC,

17 Facility Assessment GUIDANCE (e) Furthermore, the assessment must include a competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. This also includes any ethnic, cultural, or religious factors that may need to be considered to meet resident needs, such as activities, food preferences, and any other aspect of care identified. Finally, the assessment should consider a review of individual staff assignments and systems for coordination and continuity of care for residents within and across these staff assignments. Also refer to F553, Resident Rights for more information and guidance on cultural competence Staff Competency Providigm, LLC,

18 Competency Defined DEFINITIONS (e) Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual needs to perform work roles or occupational functions successfully. New Survey Pathways Providigm, LLC,

19 Staff Competency GUIDANCE (a)(3)-(4),(c) As required under F838, (e), the facility s assessment must address/include an evaluation of staff competencies that are necessary to provide the level and types of care needed for the resident population. Additionally, staff are expected to demonstrate competency with the activities listed in the training requirements per , such as preventing and reporting abuse, neglect, and exploitation, dementia management, and infection control. Also, nurse aides are expected to demonstrate competency with the activities and components that are required to be part of an approved nurse aide training and competency evaluation program, per Nursing Staff Competency GUIDANCE (a)(3)-(4),(c) Competency in skills and techniques necessary to care for residents needs includes but is not limited to competencies in areas such as; Person Centered Care Communication Basic Nursing Skills Basic Restorative Services Skin and Wound Management Medication Management Pain Management Infection Control Resident Rights Identification of Changes in Condition Cultural Competency Providigm, LLC,

20 Demonstration of Competency GUIDANCE (a)(3)-(4),(c) Lecture with return demonstration for physical activities; A pre- and post-test for documentation issues; Demonstrated ability to use tools, devices, or equipment that were the subject of training and used to care for residents; Reviewing adverse events that occurred as an indication of gaps in competency; or Demonstrated ability to perform activities that is in the scope of practice an individual is licensed or certified to perform. Nursing leadership with input from the Medical Director should delineate the competencies Staff Assignments GUIDANCE (a)(3)-(4),(c) Finally, the assessment should consider a review of individual staff assignments and systems for coordination and continuity of care for residents within and across these staff assignments. Also refer to F553, Resident Rights for more information and guidance on cultural competence. Providigm, LLC,

21 Training Requirements Training Requirements A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at (e). Facility Assessment: Facility Resources Providigm, LLC,

22 Facility Assessment Facility Resources 2) The facility's resources, including but not limited to: (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non-medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. Facility Assessment - Resources GUIDANCE (e) The facility assessment must include an evaluation of any contracts, memorandums of understanding including third party agreements for the provision of goods, services or equipment to the facility during both normal operations and emergencies. The facility assessment must address their process for overseeing these services and how those services will meet resident needs and regulatory, operational, maintenance, and staff training requirements. For example, if the facility contracts for language translation, the assessment must address how those contractors will ensure services are provided both during normal operational hours and during emergencies. Providigm, LLC,

23 Facility Assessment - Resources GUIDANCE (e) The facility assessment must consider health information technology resources, such as managing resident records and electronically sharing information with other organizations. For example, the assessment should address how the facility will securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility. Facility Assessment - Resources GUIDANCE (e) The facility assessment must include an evaluation of the physical environment necessary to meet the needs of the residents. This must include an evaluation of how the facility needs to be equipped and maintained to protect and promote the health and safety of residents. This should also include an evaluation of building maintenance capital improvements, or structures, vehicles, or medical and non-medical equipment and supplies Providigm, LLC,

24 All Hazards Risk Assessment Facility Assessment: Phase 2 (3) A facility-based and community-based risk assessment, utilizing an allhazards approach, including missing residents Providigm, LLC,

25 Common Standards All Hazards 1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier. 2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment. 3. Communication plan: Develop and maintain a communication plan that complies with both Federal and State law. Patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems. 4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan. Hazards Risk Assessment GUIDANCE (e) The facility based and community-based risk assessment, utilizing an all-hazards approach must evaluate the facility s ability to maintain continuity of operations and its ability to secure required supplies and resources during an emergency or natural disaster. For example, if the facility is located in a flood zone, the risk assessment must include an evaluation of how residents will be kept safe and needs met during a flood affecting the facility. Facility staff should consider involving their local/county Office of Emergency Preparedness when conducting this community based risk assessment. The facility s emergency preparedness plans as required under should be integrated and compatible with the facility assessment. As one is updated, so should the other. Providigm, LLC,

26 Hazard Vulnerability Assessment Tool Hazard Vulnerability Assesssments GUIDANCE (e) Hazard Vulnerability Assessments (HVAs) are systematic approaches to identifying hazards or risks that are most likely to have an impact on a healthcare facility and the surrounding community. The HVA describes the process by which a provider or supplier will assess and identify potential gaps in its emergency plan(s). Potential loss scenarios should be identified first during the risk assessment. Once a risk assessment has been conducted and an facility has identified the potential hazards/risks they may face, the organization can use those hazards/risks to conduct a Business Impact Analysis. Providigm, LLC,

27 Survey Procedures Facility Assessment Survey Impact Negative Survey Outcome Competency and Staffing Facility Assessment QAPI Plan Administration Governing Body Providigm, LLC,

28 Survey Procedures PROCEDURES (e) PROCEDURES (e) If systemic care concerns are identified that are related to the facility s planning, review the facility assessment to determine if these concerns were considered as part of the facility s assessment process. For example, if a facility recently started accepting bariatric residents, and concerns are identified related to providing bariatric services, did facility staff update its assessment before accepting residents with these needs to identify the necessary equipment, staffing, etc., needed to provide care that is effective and safe for the residents and staff? Survey Questions PROCEDURES (e) Questions surveyors should consider include, but are not limited to, the following: How did the facility assess the resident population? Does this reflect the population observed? How did the facility determine the acuity of the resident population? How did the facility determine the staffing level? How did the facility determine what skills and competencies would be required by those providing care? Providigm, LLC,

29 Survey Questions PROCEDURES (e) Questions surveyors should consider include, but are not limited to, the following: Who was involved in conducting the facility assessment? How did the facility determine what equipment, supplies, and physical environment would be required to meet all resident needs? How did the facility develop its emergency plan? If a deficient practice is systemic and is observed at another tag, was this related to an incomplete facility assessment? How? Service Limitations Providigm, LLC,

30 Admission, Transfer, and Discharge (a)(6) (6) A nursing facility must disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility SC Draft%20Appendix%20PP%20(1)%20(1).PDF Facility Limitations and Characteristics Guidance (a)(6) Facility Special Characteristics Facilities may choose to offer specialized care or services, such as a rehabilitation, dementia, or a mechanical ventilation unit. To enable potential residents and resident representatives to make informed decisions in choosing a facility for admission, facilities must inform residents and Effective November 28, 2017 resident representatives and potential residents or representatives of any special characteristics or service limitations the facility may have prior to admission. For example, a facility may have a religious affiliation that guides its practices and routines which must be communicated to any potential resident. Providigm, LLC,

31 Facility Limitations and Characteristics Guidance (a)(6) Facility Special Characteristics Likewise, if a facility has limitations in the type of medical care it can provide, this information must be communicated prior to admission. For example, if the need for a specific type of care or service becomes necessary, knowledge of service limitations may make the need for transfer or discharge more predictable and understandable for the resident and/or his or her representative. Disclosure of facility special characteristics does not relieve a facility of its responsibility to provide required nursing and other services for which it is licensed and certified to provide. To see the required services, refer to sections 1819(a) and 1819(b)(4)(A), and sections 1919(a) and 1919(b)(4)(A) of the Act. Transfer Discharge Guidance F 622 Section (c)(1)(i) provides that The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless. This means that once admitted, for most residents (other than short-stay rehabilitation residents) the facility becomes the resident s home. Facilities are required to determine their capacity and capability to care for the residents they admit. Therefore, facilities should not admit residents whose needs they cannot meet based on the Facility Assessment. (See F838, Facility Assessment). There may be rare situations, such as when a crime has occurred, that a facility initiates a discharge immediately, with no expectation of the resident s return. Providigm, LLC,

32 Linking the Facility Assessment and QAPI Facility Assessment QAPI Plan Measures Corrective Actions and PIPs Providigm, LLC,

33 QAPI Program: Governance and Leadership Program Governance and Leadership QAPI (f) Governance and leadership. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: (1) An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. (2) The QAPI program is sustained during transitions in leadership and staffing; (3) The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed; Providigm, LLC,

34 Program Governance and Leadership (4) The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. (5) Corrective actions address gaps in systems, and are evaluated for effectiveness; and (6) Clear expectations are set around safety, quality, rights, choice, and respect. QA & A Committee Providigm, LLC,

35 QA & A Committee (g)(2) Quality assessment and assurance The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. QA & A Committee (g)(2) Quality assessment and assurance committee The committee must: (i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary. (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. [ (g)(2)(ii) implemented November 28, 2016 (Phase 1) except as related to implementation of the QAPI program, which will be implemented November 28, 2019 (Phase 3)] Providigm, LLC,

36 Qaulity Assessment and Assurance (g)(1) (g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (iv) The infection preventionist. [483.75(g)(1)(iv) Implemented beginning November 28, 2019(Phase 3)] Corrective Action DEFINITIONS (g)(2)(ii)-(iii) Corrective Action : A written and implemented plan of action for correcting or improving performance in response to an identified quality deficiency. Use of the term corrective action in this guidance is not synonymous with a Plan of Correction (formal response to cited deficiencies). This is also separate from the written QAPI plan. Providigm, LLC,

37 Corrective Action DEFINITIONS (g)(2)(ii)-(iii) Once a quality deficiency is identified, the QAA committee has a responsibility to oversee development of appropriate corrective action. An appropriate corrective action is one that appears to address the underlying cause of the issue comprehensively, at the systems level. Corrective Actions Definition of the Problem/Root Cause Monitor Changes/PDSA Cycle/PIP Corrective Action Measurable Goals and Targets Step by Step Interventions Providigm, LLC,

38 Identifying Quality Deficiencies DEFINITIONS (g)(2)(ii)-(iii) The QAA committee s responsibility to identify quality deficiencies requires facilities to have a system for monitoring departmental performance data routinely in order to identify deviations in performance and adverse events. Issues identified must be prioritized to determine which concerns pose a high risk to resident safety, health, and well-being, those which are problem prone, and those which are high volume (occur with frequency). Adverse events, such as the elopement without injury of a cognitively-impaired resident, should be considered a high risk problem for which corrective action is required. Adverse Event: An untoward, undesirable, unanticipated event that causes death or serious injury or the risk thereof, which include near misses. Facilities must have mechanisms or systems in place to ensure the QAA Committee takes necessary steps to identify the cause and correct the issue. Providigm, LLC,

39 Adverse Event Identification When an event occurs, how is it identified? High risk data? Harm? What is the root cause of the problem? Corrective Action Can you produce a corrective action plan? How is the plan monitored for effectiveness, for how long? Assessing Resource Are failures to identify population needs/assessment related? Are resources available, staff, equipment, competency and staffing? Potentially Preventable Adverse Events Providigm, LLC,

40 Survey Procedures QAA & QAPI Plan Review Providigm, LLC,

41 QAA & QAPI Plan Review QAA & QAPI Plan Review Providigm, LLC,

42 Performance Improvement Program Activities- Results of QAPI program Program Activities (e) Program activities, ( implemented during Phase 3) (1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care. (2) Performance improvement activities must Track medical errors and adverse resident events, Analyze their causes, and Implement preventive actions and mechanisms that include feedback and learning throughout the facility. Providigm, LLC,

43 Program Activities PIPS (e)(3) (e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at (e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section QAPI Providigm, LLC,

44 Quality Assurance and Performance Improvement This section will be implemented in Phase 3 (November 28, 2019) with the following exceptions: (a)(2) Initial QAPI Plan must be provided to State Agency Surveyor at annual survey Implemented in Phase 2. (November 28, 2017) (g)(1) QAA committee All requirements of this section will be implemented in Phase 1 (November 28, 2016) with the exception of subparagraph (iv), the addition of the ICPO, which will be implemented in Phase 3 (November 2019). (h) Disclosure of information Implemented in Phase 1 (November 28, 2016). (i) Sanctions Implemented in Phase 1(November 28, 2016) Quality Assurance and Performance Improvement (a) Quality assurance and performance improvement (QAPI) program. Each LTC facility, including a facility that is part of a multiunit chain, must Develop Implement, and Maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Providigm, LLC,

45 Maintain Documentation and Evidence of Implementation (a)(1) The facility must (1) Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities; Corrective Actions /Performance Improvement Systematic Identification high risk, high volume, problem prone Prevention Adverse Events/System Deviation QAPI System and Documentation Reporting Analysis Investigation Providigm, LLC,

46 QAPI Plan: Phase (a)(2) (2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation; (3) Present its QAPI plan to a State Survey Agency or Federal surveyor at each annual recertification survey and upon request during any other survey and to CMS upon request; and (4) Present documentation and evidence of its ongoing QAPI program's implementation and the facility's compliance with requirements to a State Agency, Federal surveyor or CMS upon request. QAPI Intent These requirements are intended to ensure facilities develop a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Providigm, LLC,

47 QAPI Plan GUIDANCE (a)(2)-(3), and (h)-(i) A QAPI plan is the written plan containing the process that will guide the nursing home s efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. The plan describes how the facility will conduct its required QAPI and QAA committee functions. The facility is required to develop a QAPI plan and present its plan to federal and state surveyors at each annual recertification survey and upon request during any other survey, and to CMS upon request. QAPI Plan GUIDANCE (a)(2)-(3), and (h)-(i) The QAPI plan must describe How the facility will ensure care and services delivered meet accepted standards of quality, Identify problems and opportunities for improvement, And ensure progress toward correction or improvement is achieved and sustained. Providigm, LLC,

48 QAPI Plan GUIDANCE (a)(2)-(3), and (h)-(i) The QAPI plan must describe the process for identifying and correcting quality deficiencies. Key components of the process include: Tracking and measure performance; Establishing goals and thresholds for performance measurement; Identifying and prioritizing quality deficiencies; Systematically analyzing underlying causes of systemic quality deficiencies; Developing and implementing corrective action or performance improvement activities; and Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. QAPI Plan: Key Process Components for Identifying and Correcting Quality Deficiencies Tracking and Measuring Performance Establishing goals and thresholds for performance measurement Identifying and prioritizing quality deficiencies Systematically analyzing underlying causes of systemic quality deficiencies Developing and implementing corrective action or performance improvement activities Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed Providigm, LLC,

49 Program Design and Scope Program Design and Scope (b) Program design and scope. (b) Program design and scope. A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must: (1) Address all systems of care and management practices; (2) Include clinical care, quality of life, and resident choice; Identified in the Facility Assessment Providigm, LLC,

50 Program Design and Scope (b) Program design and scope. (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 for residents of a SNF or NF. (4) Reflect the complexities, unique care, and services that the facility provides. Measures reflect service delivery and processes identified in facility assessment Nursing Home Compare Metrics What care and services are represented by these outcomes? Providigm, LLC,

51 All Causes Readmission SNFVBP As a reminder, the SNFRM does not assess the rate of readmission for SNF patients to a SNF following discharge. The measure instead assesses the rate of readmission of SNF patients to an IPPS hospital or CAH, either before or after discharge from the SNF, within 30 days of discharge from a prior hospitalization. SNF QRP Measures for 2018 Payment Determination Percent of Patients/Residents with Pressure Ulcers that are new or worsened (short stay) (MDS) Percent of Residents Experiencing one or more Falls with Major Injury(long stay) ( MDS) Application of the Percent of Long Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a care plan that addresses function (MDS DC to Community- Post acute care (PAC) (claims based) Potentially Preventable 30 Day Post-Discharge Readmission Measure for SNF (claims based) Medicare Spending per Beneficiary (MSPB) (claims based) These measures will be posted for consumers Providigm, LLC,

52 QAPI Program: Feedback, Data Systems and Monitoring Program Feedback, Data Systems, and Monitoring (c) Policies and Procedures (c) Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for Feedback, Data collections systems, and Monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: (1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care/direct access workers, other staff, residents, and resident representatives, (2) How such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement. Providigm, LLC,

53 Resident Interview: Obtaining Feedback thru Data Collection Resident feedback populates metrics. Resident Interview: Reporting and Analysis Use of Feedback, Reporting, and Analysis! High Risk! Problem Prone Providigm, LLC,

54 Program Feedback, Data Systems and Monitoring (c)(1) Policies and Procedures (2) Facility maintenance of effective systems to Identify, Collect, and Use data from all departments, including but not limited to the facility assessment required at (e) and include how such information will be used to develop and monitor performance indicators. Policy and Procedure required linking data from the facility assessment Program Feedback, Data Systems and Monitoring (c)(1) Policies and Procedures (3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation. (4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events. Providigm, LLC,

55 Measure Monitoring QAPI Program: Systematic Analysis and Systemic Action Providigm, LLC,

56 Systemic Care Concerns Systemic care concerns will be evaluated in relationship to the facility assessment. Systemic care concerns will also be evaluated at the end of the survey in the QAA/QAPI process. These areas are linked through governing body and administration requirements. What systems, policies and procedures have been put into place to identify and correct deficient practice? Program Systematic Analysis and Systemic Action (d)(1), (d)(2) Policies (d) Program systematic analysis and systemic action. (1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. (2) The facility will develop and implement policies addressing: (i) How they will use a systematic approach (such as root cause analysis, reverse tracer methodology, or health care failure and effects analysis) to determine underlying causes of problems impacting larger systems; Providigm, LLC,

57 Program Systematic Analysis and Systemic Action (d)(2) Policies (ii) Development of corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Disclosure of Information Providigm, LLC,

58 Disclosure of Information (h) (h) Disclosure of information. (1) A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. (2) Demonstration of compliance with the requirements of this section may require State or Federal surveyor access to: (i) Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; (ii) Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities; and (iii) Other documentation considered necessary by a State or Federal surveyor in assessing compliance. Sanctions (i) Sanctions, Good Faith Attempts GUIDANCE (a)(2)-(3), and (h)-(i) (i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions. Good Faith Attempts : If the facility, through its QAA committee, has identified and made a good faith attempt to correct the same issue identified by the survey team during the current survey, the facility will not be cited for QAA (it may however, still be cited with deficiencies related to actual or potential issues at other relevant tags). A good faith attempt to correct an identified quality deficiency involves determining where a facility is within the process of identifying and correcting a problem (or problems) Providigm, LLC,

59 Sanctions Thus, since access to QAA committee records may be necessary to determine whether a facility meets the Medicare requirements at , denial of such access risks termination of the provider agreement. Contact Cindy Mason VP Provider Services cmason@providigm.com twitter.com/providigm facebook.com/providigm Providigm, LLC,

60 Contact for abaqis information Ellen Kuebrich CSMO twitter.com/providigm facebook.com/providigm Providigm, LLC,