Quality Assurance and Performance Improvement (QAPI)

Quality care is the heart of what we do, and QAPI is the road to get there! You may be thinking that is easier said than done. The resources below have been gathered to assist you in achieving your facility goals for quality care outcomes. Need another reason to better understand QAPI? As value-based payment becomes a reality, facilities are required to demonstrate the quality of care to consumers and payers, continuously improving efficiency and resident outcomes. Learn how you can get ahead of the game with helpful resources.

  • CDC Training: Legionella Water Management Programs (5/19)

    By CDC - May 02, 2019
    Preventing Legionnaires’ Disease: A Training on Legionella Water Management Programs (PreventLD Training)
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  • May 30 Webinar Early Identification of Sepsis in Nursing Facilities: Opportunities and Hurdles: Register Now

    By NNHQIC - May 01, 2019

    Please join Christine LaRocca, MD and the National Nursing Home Quality Improvement Campaign to learn more about sepsis, who is at risk and the signs and symptoms for early detection. In addition, we will:

    ·        Review examples of sepsis screening tools commonly used in hospital settings;

    ·        Learn what tools to use while recognizing the limitations of sepsis screening tools in the nursing home population; and 

    ·        Understand the elements of evidence-based treatment for optimal outcomes.

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  • SNF QRP SNF Provider Preview Reports - Now Available (5/19)

    By CMS - May 01, 2019
    Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. The data contained within the Preview Reports is based on quality data submitted by SNFs between Quarter 4 – 2017 and Quarter 3 – 2018, for assessment-based quality measures, and between Quarter 1 – 2017 to Quarter 4 – 2017, for claims-based quality measures. Providers have until May 30, 2019 to review their performance data prior to the July 2019Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate. 
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  • FY 2020 and FY 2021 SNF QRP Program Data Collection & Final Submission Deadlines (5/19)

    By CMS - April 23, 2019

    Skilled Nursing Facility Quality Reporting Program Data Collection & Final Submission Deadlines for the FY 2020 and FY 2021 SNF QRP

    These two tables provide the data collection time frames and final submission deadlines for the Fiscal Year (FY) 2021 Skilled Nursing Facility Quality Reporting Program (SNF QRP) and FY 2021 SNF QRP. The first column  in each table displays the measure name, the second column displays the data collection time frame, and the third column displays the final data submission deadlines.


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    • Five-Star Technical User's Guide UPDATED AGAIN (4/19)

      By CMS - April 17, 2019

      CMS created the Five-Star (5-Star) Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them. Updated twice in April 2019.

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    • SNF QRP Review and Correct Reports Now Available (4/19)

      By CMS - April 05, 2019

      The enhanced Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) review and correct reports are now available, on demand in the Certification and Survey Provider Enhanced Reporting (CASPER) application. In addition to enhanced sorting functionality, this report now includes patient level data and automated CSV file creation functionality that contains patient level results. Providers can access these reports by selecting the CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage.

      NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage.

      In addition to the sorting enhancements and inclusion of resident level data, these reports:

      • Contain quality measure information at the facility level
      • Allow providers to obtain aggregate performance for the past four quarters (when data is available)
      • Include data submitted prior to the applicable quarterly data submission deadlines
      • Display whether the data correction period for a given CY quarter is “open” or “closed.
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    • Nursing Home Compare Claims-based Measures Technical Specifications Plus Appendix Updated (3/19)

      By CMS - March 27, 2019

      Nursing Home Compare Claims-based Measures Technical Specifications, including Five-Star QMs -Update March 2019  plus Appendix

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    • Remote Identify Proofing Requirements for Internet Quality Improvement Evaluation System (iQIES) (3/19)

      By QTSO - March 19, 2019


      The Centers for Medicare & Medicaid Services (CMS) serves a critical quality assurance function for our country’s healthcare system.  Quality Improvement and Evaluation System (QIES) will undergo a series of system enhancements resulting in what will be now called the Internet Quality Improvement and Evaluation Systems (iQIES).  

      To comply with federal security mandates, CMS is initiating new security requirements for access control to CMS Quality Systems through Remote Identify Proofing (RIDP) via the HCQIS (Healthcare Quality Information System) Access, Roles and Profile Management system. Users will create accounts in HCQIS Access Roles and Profile Management (HARP) to gain access to the iQIES system.

      What is Remote Identify Proofing? 

      Remote proofing is a method for verifying the identity of a user remotely, as opposed to manual proofing or in-person proofing. Based on user-entered data, the HARP system uses Experian to generate a list of personal questions for the user to answer to verify their identity remotely. Remote proofing is the HARP-recommended method for identity verification, as it is typically much faster than other methods of identity proofing. If a user cannot successfully complete remote proofing during HARP registration, he/she will need to initiate manual proofing.

      Why is Remote Identify Proofing Necessary?

      The primary purpose of RIDP is to eliminate unauthorized access, reduce fraud, minimize manual processing, and prevent compromise of personally identifiable information (PII). These changes are designed to be compliant with federal and CMS guidelines and requirements such as OMB M04-04e-Authentication Guidance for Federal Agencies, HSPD-12, NIST 800-53 & 63, FISMA, FIPS 199 Standards, FIPS 200 and OMB M07-16. 

      What happens to the personal information used to register?

      CMS does not store your personal information received for the purposes of RIDP. It only passes it to the credit reporting agency, an external identity verification system, to help confirm your identity. Your personal information is described as data that is unique to you as an individual, such as name, address, telephone number, Social Security Number, and date of birth. 

      Additional communication about iQIES program information including but not limited to onboarding, stakeholder engagement opportunities, training and general updates are in development and will be distributed in the coming weeks. For assistance with HARP onboarding, users can call the QTSO Helpdesk at (800) 339-9313 or e-mail help@qtso.com

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    • SNF Review and Correct Report Available (3/19)

      By QTSO - March 15, 2019

      SNF users were notified by CMS on Monday, March 11, that the Review and Correct report in the ‘SNF Quality Reporting Program ‘ category in the CASPER Reporting application would be unavailable while enhancements were being applied to the report. This report is now available and contains the following enhancements:

      • The addition of two new measures starting April 1, 2019:
       -Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
       -Drug Regimen Review Conducted with Follow-up for Identified Issues – PAC SNF QRP
      • The removal of one measure starting with Q4 2018 results:
       -Percent of Residents or Patients with Pressure Ulcers That are New or Worsened (Short Stay) (NQF#0678)
      • The addition of Resident-Level data will now display with the Facility-Level data results.
       -A .csv file output will be available for the Patient-Level data
      • The Resident-Level and Facility-Level data will have new filter/sorting functionality within the CASPER Report Submit screen to customize the reporting results.

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    • CDC/CMS Free Infection Preventionist Training Course and CMS QSO Memo (3/19)

      By CDC/CMS - March 12, 2019

      Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long-Term Care Setting is Now Available

      The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) collaborated on the development of a free on-line training course in infection prevention and control for nursing home staff in the long-term care setting.

      The training provides approximately 19 hours of continuing education credits as well as a certificate of completion (i.e., free CME, CNE or CEUs).

      The course introduces and describes how to use IPC program implementation resources including policy and procedure templates, audit tools, and outbreak investigation tools.

      The course is made up of 23 modules and sub-modules that can be completed in any order and over multiple sessions.

      The course covers:

      • Core activities of effective IPC programs
      • Recommended IPC practices to reduce
      • Pathogen transmission
      • Healthcare-associated infections
      • Antibiotic resistance
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    • CASPER Reporting User’s Guide for MDS Providers UPDATED (3/19)

      By QTSO - March 11, 2019
      Provides information and instructions pertaining to CASPER Reporting, including accessing Final Validation Reports.
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    • Do You Know How To Access CMP Funds? (3/19)

      By OIG - March 10, 2019

      The OIG report, Michigan Disbursed Only Part of Its Civil Money Penalty Collections, Limiting Resources To Protect or Improve Care for Nursing Facility Residents (02-28-2019 | Audit (A-05-17-00019) | Complete Report | Report in Brief) found that the state of Michigan did not fully use available civil monetary penalty (CMP) collections to support nursing facility residents. While the report is specific to Michigan, it suggests some providers across the United States may not be aware of/know how to apply for CMP funds or know what types of projects are likely to receive funding.

      How to Apply for CMP Funds

      The application process for CMP funds is determined by the state in which the nursing home is located. The process for each state may differ therefore states have their own applications for CMP funds and applicants should use their state specific application and instructions.

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    • CMS Press Release on April 2019 Nursing Home Compare / Five-Star Changes (3/19)

      By CMS - March 05, 2019

      The April 2019 changes include revisions to the inspection process, enhancement of new staffing information, and implementation of new quality measures.

      This includes a lifting of the ‘freeze’ on the health inspection ratings instituted in February 2018. CMS ‘froze’ the health inspection star ratings category after implementing a new survey process for Long-Term Care facilities. Because facilities receive surveys at different times, some facilities would have been surveyed under the old process and others under the new process. Without placing a ‘freeze’ on health inspection star ratings, the facilities would have been scored using two different evaluation processes making the outcomes misaligned and the data inaccurate. CMS ‘froze’ the health inspection star rating score until all nursing homes were surveyed at least once under the new survey process for Long Term Care facilities. Ending the freeze is critical for consumers. In April, they will be able to see the most up to date status of a facility’s compliance, which is a very strong reflection of a facility’s ability to improve and protect each resident’s health and safety.

      Additionally, CMS is setting higher thresholds and evidence-based standards for nursing homes’ staffing levels. Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes. CMS found that as staffing levels increase, quality increases and is therefore assigning an automatic one-star rating when a Nursing Home facility reports “no registered nurse is onsite.” Currently, facilities that report seven or more days in a quarter with no registered nurse onsite are automatically assigned a one-star staffing rating. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days. CMS is also making changes to the quality component on Nursing Home Compare that would improve identifying differences in quality among nursing homes, raise expectations for quality, and incentivize continuous quality improvement.

      To provide further value and remain consistent with CMS’s Meaningful Measures initiative the April 2019 Nursing Home Compare Update includes adding measures of long-stay hospitalizations and emergency room transfers, and removing duplicative and less meaningful measures. CMS is also establishing separate quality ratings for short-stay and long-stay residents and revising the rating thresholds to better identify the differences in quality among nursing homes making it easier for consumers to find the right information needed to make decisions.

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    • CMS QSO memo: April 2019 Changes to Nursing Home Compare / Five Star (3/19)

      By CMS - March 05, 2019

      April 2019 Improvements to Nursing Home Compare include:

      Ending the Freeze on Health Inspection Star Ratings - In April 2019, the Centers for Medicare & Medicaid Services (CMS) will end the freeze on the health inspection domain of the Five Star Quality Rating System. We will resume the traditional method of calculating health inspection scores by using three cycles of inspections. Inspections occurring on or after November 28, 2017, will be included in each facility’s star rating.


      Quality Measure (QM) Domain Improvements – CMS is introducing separate ratings for short- and long-stay measures to reflect the level of quality provided for these two subpopulations in nursing homes. We are also revising the thresholds for ratings, adding a system for regular updates to thresholds every six months, and weighting and scoring individual QMs differently. Additionally, we are adding the long-stay hospitalization measure and a measure of long-stay emergency department (ED) transfers to the rating system. Two measures from the Skilled Nursing Facility Quality Reporting Program (QRP) will be adopted to replace duplicative existing measures.


      Staffing Domain Improvements – CMS is adjusting the thresholds for staffing ratings. Also, the threshold for the ‘number of days without a registered nurse (RN) onsite’ that triggers an automatic downgrade to one star will be reduced from seven to four days.

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    • CMS QSO Memo: Enhanced Oversight and Enforcement of Non-Improving Late Adopters re: Antipsychotic Meds (3/19)

      By CMS - March 03, 2019

      • The National Partnership & Identification of Late Adopters – Since 2011, the Centers for Medicare & Medicaid Services (CMS) has seen a reduction of 38.9 percent in long-stay nursing home residents who were receiving an antipsychotic medication. Despite the success of the National Partnership, CMS identified approximately 1,500 facilities that had not improved their antipsychotic medication utilization rates for long-stay nursing home residents, referred to as late adopters. In December 2017, CMS notified these facilities of this identification.

      • Enforcement for A Segment of Non-Improving Late Adopters with Multiple Citations - As of January 2019, there are 235 late adopter nursing homes that have been cited for noncompliance with federal regulations related to unnecessary medications or psychotropic medications two or more times since January 1, 2016, and who have not shown improvement in their long-stay antipsychotic medication rates. If these facilities are determined not to be in substantial compliance with requirements for Chemical Restraints, Dementia Care, or Psychotropic Medications during a survey, they will be subject to enforcement remedies for such noncompliance.

      • Corporate Engagement - CMS is also looking for opportunities to engage with corporate chains that have significant numbers of nursing homes identified as late adopters.

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