It’s QAPI Time!

by | Mar 29, 2017 | QAPI

Explore More Posts from MDS Consultants

QAPI will soon be in the spotlight.  All skilled nursing facilities, by November 28 of this year, must have their QAPI plan ready to provide to the Annual Survey.  For those who don’t have their plan in place, here is a quick QAPI primer.

What Is QAPI?

QAPI stands for Quality Assurance / Performance Improvement.  The ultimate goal is a “data-driven, proactive approach to improving the quality of life, care and services in nursing homes” achieved through the combined elements of both practices (QA and PI).

The CMS QAPI Guide illustrates the merging of the concepts by highlighting their different approaches to quality management:

Quality Assurance (QA)

Performance Improvement (PI)

Motivation

Measuring compliance with standards

Continuously improving processes to meet standards

Means

Inspection

Prevention

Attitude

Required, reactive

Chose, proactive

Focus

Individuals/outliers (“bad apples”)

Processes or Systems

Scope

Medical provider

Resident care

Responsibility

Few

All

Combine both and you arrive at the end result:  QAPI = QA + PI

 Why Do I Care?

Section 6102(c) of the Affordable Care Act requires all skilled nursing facilities develop a QAPI program (Phase II), with CMS directed to develop a QAPI prototype program (Phase I) along with standards, technical assistance and best practices guidance.  CMS completed Phase I on November 28, 2016 – which means the deadline for Phase II (provide an initial QAPI plan for your facility to the State Agency Surveyor at your annual survey) is November 28, 2017.  The Phase III (have the QAPI plan implemented) deadline is November 28, 2019.

What Do I Need to Do?

Time to develop your QAPI plan.  Per CMS guidelines, five program elements need to be included in your QAPI plan:

  • Design and Scope
  • Governance and Leadership
  • Feedback, Data Systems and Monitoring
  • Performance Improvement Projects (PIPs)
  • Systematic Analysis and Systemic Action

 Where Can I Find Resources?

The good news is that there are many resources available to assist you in the development of your QAPI plan (including program guides, worksheets, assessments, checklists and planners).  Check out our website for links to over two dozen resources you can access for assistance.  Our QAPI experts are also available to help answer your questions.

Explore More Posts from MDS Consultants

Get ready for October 1

Transportation – New Item A1250

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See An additional item we will see in the upcoming MDS 3.0 v.1.18.11 in October 2023 is A1250 - Transportation. This is included in a new subset of...

New 3-day Lookbacks | Assessment Periods

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of March 24, 2023 What You Can Expect to See New 3-day lookback/assessment periods are coming to the MDS world. There are different sections of the MDS that the Nurse Assessment Coordinators...

New Pain Interview in Section J

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of February 22, 2023 What You Can Expect to See The most noticeable changes to Section J are evident in the pain interview, specifically questions J0510, J0520 and J0530. The RAI Manual has...

Section B – Hearing, Speech and Vision Changes

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See Section B on the MDS is a component of the Standardized Patient Assessment Data Elements (SPADEs), which is utilized across post-acute care...

Race and Ethnicity – Changes in Section A

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See Section A, Identification Information for Race/Ethnicity has expanded. One of the major changes is the deletion of section A1000 Race/Ethnicity....

Read more on Toolbox Essentials

Focused Infection Control Surveys and Directed Plan of Correction

It's a dreary Monday morning, and the state surveyors walk into your facility to conduct a Focused Infection Control survey. You and your team have been trying your hardest to comply with infection control procedures throughout the pandemic. At the end of the survey,...

New Advanced Beneficiary Notice

Is your facility using the proper ABN form? The Centers for Medicare & Medicaid Services (CMS) recently updated the Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131. The new ABN will be mandatory for use on 1/1/2021, but the new form can be...

Covid-19 and Skilled Status

In late June, CMS addressed two issues and posted MDS 3.0 Final Item Sets (V1.17.2).  The two edits were changes to facilitate the calculation of Patient-Driven Payment Model payment codes on OBRA assessments for states that wish to have this calculation performed. ...

Mind Your PHQs

Some skilled nursing facilities (SNFs) are concerned about accurate payment when a resident unexpectedly discharges and the Brief Interview for Mental Status (BIMS) has not yet been completed.However, they should be just as concerned about the PHQ-9. The PHQ-9...

MDS in the Emergency Preparedness Plan

The COVID-19 pandemic has highlighted the need for skilled nursing facilities to have an effective Emergency Preparedness Plan - one that includes sheltering-in-place. The Centers for Medicare and Medicaid Final Rule requires that participating providers have an...

MORE from MDS Experts

Coding UTIs on the MDS 3.0

Urinary Tract Infections (UTIs) are a commonly miscoded data element on the MDS. Are you over coding UTIs? Are you not coding them at all? Should you? Shouldn’t you? The MDS has historically left data collectors asking themselves these questions. What happens if I do...

Achieving Accurate ADLs with the OSA

Section G of the MDS 3.0 was retired October 1, 2023, yet the MDS nurse may still need to use the knowledge of accurately coding ADLs with an assessment called the Optional State Assessment (OSA).  State-Optioned OSA Although the option to choose an OSA from the...

What Is an MDS Coordinator?

It’s a bit odd that when asked what you do for a living most MDS coordinators struggle to come up with an answer. Who struggles to explain what they do every day? The reality is that MDS Coordinators fully understand what this multifaceted job entails, but are at a...

MDS 2023 Countdown Wrap-Up

This post is part of the MDS 2023 Countdown series.  Disclaimer: Current as of May 13, 2023.   What You Can Expect to See CMS released the first MDS draft item set (v1.18.11) in September 2022, which generated many questions for the long-term care community. Both...

Rx Reconciliation – New SNF QRP and QMs

This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of October 1, 2023 What You Can Expect to See The reconciled medication list will have a new documentation requirement that will go into effect with the October 1, 2023 changes to the MDS...

Webinars & Training

Grow your knowledge with our MDS education

MDS Guides & Forms

Exclusive resources & tools we use every day

Ask an Expert Forum

Members can get 1:1 advice from our MDS experts

Let's Meet in Person

Get more info on our training & conference schedule

News for MDS Experts

Browse our blog & get news alerts on MDS changes

MDS Completion

Get your MDS' done ASAP with short-term, expert help

Remote Floater

Fill gaps on your team when & where you need

Case Mix Index

Improve your complex case mix calculations

MDS System Mgt

Best practices for MDS schedules & workflow

+ More Services

Get help on PDPM, ICD-10, quality, schizoph. audits ++