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.

  • CMS COVID-19 Nursing Homes Best Practices Toolkit and New QIN-QIO Virtual Assistance (5/20)

    By CMS - May 13, 2020

    New tool provides innovative solutions for states and facilities to protect our nation’s vulnerable nursing home residents during emergency

    CMS has released a new toolkit developed to aid nursing homes, Governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. The toolkit builds upon previous actions taken by the Centers for Medicare & Medicaid Services (CMS), which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency. The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalogue of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

    “The coronavirus presents a unique challenge for nursing homes. CMS is using every tool at our disposal to protect our nation’s most vulnerable citizens and aid the facilities that care for them. This toolkit will support state, local leaders and nursing homes in identifying best practices to protect our vulnerable elderly in nursing homes” said CMS Administrator Seema Verma.  

    The toolkit provides detailed resources and direction for quality improvement assistance and can help in the creation and implementation of strategies and interventions intended to manage and prevent the spread of COVID-19 within nursing homes. The toolkit outlines best practices for a variety of subjects ranging from infection control to workforce and staffing. It also provides contact information for organizations who stand ready to assist with the unique challenges posed by caring for individuals in long-term care settings. Each state was involved in the creation of this toolkit, resulting in a robust resource that may be leveraged by a variety of entities serving this vulnerable population.

    Additionally, CMS has contracted with 12 Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) to work with providers, community partners, beneficiaries and caregivers on data-driven quality improvement initiatives designed to improve the quality of care for beneficiaries across the United States. The QIN-QIOs are reaching out to nursing homes across the country to provide virtual technical assistance for homes that have an opportunity for improvement based on an analysis of previous citations for infection control deficiencies using publicly available data found on Nursing Home Compare.

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  • Five-Star Technical User's Guide Plus Claims-Based Measures Appendix (4/20)

    By CMS - April 30, 2020

    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 October 2019.


    April 2020 Revisions: Temporary Changes due to COVID-I9 

    On March 23, CMS announced a new, targeted inspection plan designed to help keep nursing home residents safe in the face of the COVID-19 pandemic. The plan called for focused inspections on urgent patient safety threats (called “immediate jeopardy”) and infection control. These targeted inspections allow CMS to focus inspections on the most urgent situations, so the agency can get the information it needs to ensure safety, while not getting in the way of patient care. Due to this action, there is a great shift in the number of nursing homes inspected, and how the inspections are conducted. Without action, this would disrupt the inspection domain of the Five Star Quality Rating System because many nursing homes that would normally be inspected, will not, thereby over-weighting and impacting the ratings of those facilities that are inspected. This could then potentially mislead consumers. Therefore, we will temporarily maintain and hold constant the health inspection domain of the rating system. Specifically, health inspections conducted on or after March 4, 2020, will be posted publicly, but not be used to calculate a nursing home’s health inspection star ratings. This action will start with the scheduled update to the Nursing Home Compare website on April 29, 2020. The surveys will be posted through a link on the front page of the Nursing Home Compare website in the upcoming months (as the survey data is finalized and uploaded).

     

    January 2020 addition: Technical specifications for claims-based measures

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  • COVID-19: CMS Issues SNF QRP / SNF VBP Guidance Memo (3/20)

    By CMS - March 27, 2020

    DATE: March 27, 2020

    TO: MLN Connects Newsletter and Other Program-Specific Listserv Recipients

    FROM: [Program-Specific Listservs, Partner Listservs (e.g., NHSN), ESRD Networks, CMS Emergency web page]

    SUBJECT: Exceptions and Extensions for Quality Reporting Requirements for Acute Care Hospitals, PPS-Exempt Cancer Hospitals, Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies, Hospices, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, Ambulatory Surgical Centers, Renal Dialysis Facilities, and MIPS Eligible Clinicians Affected by COVID-19

     

    The Centers for Medicare & Medicaid Services (CMS) is granting exceptions1 under certain Medicare quality reporting and value-based purchasing programs for acute care hospitals, Prospective Payment System (PPS)-exempt cancer hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, longterm care hospitals, ambulatory surgical centers, renal dialysis facilities, and Merit-based Incentive Payment System (MIPS) eligible clinicians for all providers and suppliers participating in the programs described below across the United States and its territories in response to the 2019 Novel Coronavirus (COVID-19) pandemic.

     

    On March 22, 2020, CMS announced relief for clinicians, providers, hospitals and facilities participating in quality reporting programs in response to COVID-19.2 This memorandum supplements and provides additional guidance to health care providers with regard to the announcement. The scope and duration of the exceptions under each Medicare quality reporting program and value-based purchasing program are described below. CMS is granting exceptions and extensions for certain deadlines to assist these health care providers while they direct their resources toward caring for their patients and ensuring the health and safety of patients and staff. In some instances, these exceptions and extensions are granted because the data collected may be greatly impacted by the response to COVID-19 and therefore should not be considered in the quality reporting program. CMS is closely monitoring the situation for potential adjustments and will update exception lists, exempted reporting periods, and submission deadlines accordingly as events occur.

     

    Home Health Agencies (HHAs), Hospices, Inpatient Rehabilitation Facilities (IRFs), LongTerm Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs)

    CMS is granting an exception to the Quality Reporting Program (QRP) reporting requirements for all HHAs, Hospices, IRFs, LTCHs and SNFs. In accordance with 42 C.F.R. 412.560(c), 412.634(c), 413.360(c), 484.245(c), these providers are excepted from the reporting of data on measures, Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and standardized patient assessment data required under these programs for the post-acute care (PAC) quality reporting programs for calendar years (CYs) 2019 and 2020 for the following quarters specific to each program:

    • SNFs–Skilled Nursing Facility QRP
    • October 1, 2019–December 31, 2019 (Q4 2019)
    • January 1, 2020–March 31, 2020 (Q1 2020)
    • April 1, 2020–June 30, 2020 (Q2 2020)

     

    CMS finalized the SNF VBP Program’s Extraordinary Circumstances Exception (ECE) Policy in the FY 2019 SNF PPS final rule (83 FR 39280 through 39281). In accordance with § 413.338(d)(4)(iv) for the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program, CMS will exclude qualifying claims from the claims-based SNF 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510) calculation for the following periods:

    • January 1, 2020–March 31, 2020 (Q1 2020)
    • April 1, 2020–June 30, 2020 (Q2 2020)

     

    PAC QRP Extraordinary Circumstances Exception Request Information For further information about exceptions, view the program-specific web pages:

    SNF Quality Reporting Reconsideration and Exception & Extension or email questions toSNFQRPReconsiderations@cms.hhs.gov

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  • CMS Relaxes SNF QRP Data Submission Requirement Changes, SNF VBP Data Changes Due to COVID-19 (3/20)

    By CMS - March 23, 2020

    CMS is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs with respect to upcoming measure reporting and data submission for those programs. These actions are part of CMS’s response to 2019 Novel Coronavirus (COVID-19).

     

    Specifically, CMS is implementing additional extreme and uncontrollable circumstances policy exceptions and extensions for upcoming measure reporting and data submission deadlines that will impact both the SNF QRP and the SNF VBP.

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  • CASPER Reporting User’s Guide for MDS Providers UPDATED (3/20)

    By QTSO - March 23, 2020
    Provides information and instructions pertaining to CASPER Reporting, including accessing Final Validation Reports.
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  • Tuesday March 17: CDC WIll Hold COVID-19 Call for Nursing Homes

    By CDC - March 15, 2020

    Coronavirus Disease 2019 (COVID-19) Update and Information for Long-term Care Facilities

    During this COCA Call, presenters will focus on current information about COVID-19 as it relates to long-term care facilities, including nursing homes. Topics will include infection prevention and control guidance, steps facilities should take to prepare, and available resources.

    Special Request: Due to the high demand we anticipate for this COCA Call, we kindly ask participants to access it in a group format, if possible, to allow for the maximum number of people to participate.

     

    Watch on Facebook: You may also participate in this COCA Call by joining COCA's Facebook Live.  

     

    Advanced registration is not required.

     

    Continuing Education will not be offered for this COCA Call. 

     

    There will only be a few slides for this COCA Call. Slides will not advance during the presentation portion of this webinar. You can find the slides under the "Call Materials" tab here.   


    Date: Tuesday, March 17, 2020

    Time: 2:00pm–3:00pm (ET)

    Please click the link below to join:
    https://zoom.us/j/148725646

    Or iPhone one-tap:
    US: +16468769923,,148725646# or +16699006833,,148725646#   

    Or Telephone:
    US: +1 646 876 9923 or +1 669 900 6833 

    Webinar ID: 148 725 646

    International numbers available: https://zoom.us/u/anixAVglV

    If you are unable to attend this live COCA Call, it will be available to view on-demand a few hours after the call. 

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  • Developing a Restful Environment Action Manual (DREAM) Toolkit From CMS (2/20)

    By CMS - February 18, 2020

    As many as 70% of adults with dementia experience sleep disturbances, which are associated with various negative health outcomes. High quality sleep is necessary for optimal cognitive and physical functioning, especially for residents who already experience cognitive decline due to dementia. The DREAM Toolkit provides educational material and practical tools for nursing home staff to help all residents living with dementia improve sleep quality. Nursing homes can choose from a variety of strategies in the DREAM Toolkit to help improve quality of life and quality of care, especially for residents living with dementia.

    The DREAM Toolkit consists of the following components:

    1) Implementation Guide

    2) Handbook

    3) Sleep Matters Video: https://youtu.be/2Ub55iKej84  

    4) Pocket Guide for Clinical Teams

    5) Sleep Environment Improvement Tool

    6) Resident Preferences Tool

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  • Head to Toe Infection Prevention (H2T) Toolkit From CMS (2/20)

    By CMS - February 18, 2020

    Infections comprise a large share of adverse events in nursing homes. The Head to Toe Infection Prevention Toolkit contains educational materials and practical tools to support the clinical team in providing person-centered care that helps prevent and control common infections like pneumonia, skin infections, and urinary tract infections. The Toolkit aims to educate licensed nurses and nurse aides on infection prevention practices and provide tools that can be integrated into their daily work.

    The H2T Toolkit consists of the following components:

    1) Implementation Guide

    2) Infection Prevention Handbook

    3) Staff Presentation

    4) Resource for Residents and Loved Ones

    5) Observation Guide

    6) Customizing Care Tool

    7) Suspected Infection Investigation Tool

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  • Do You Know Who Your New QIN-QIO Is? (2/20)

    By Staff - February 05, 2020

    In November 2019, the Centers for Medicare & Medicaid Services quietly implemented the 12th Statement of Work for the Quality Improvement Network Quality Improvement Organizations (QIN-QIOs).

    This five-year contract includes a shift in how/where the QIN-QIOs operate. There are now 14 Medicare-funded QIN-QIOs nationwide. For example, IPRO is a lead contractor partnering with two other QIOs to cover 11 states and the District of Columbia. IPRO will direct activities in New York, New Jersey, and Ohio; Healthcentric Advisors will cover all six New England states (Maine, New Hampshire, Vermont, Massachusetts, Connecticut, and Rhode Island); and Qlarant will handle Maryland, Delaware, and the District of Columbia.

    "QIN-QIOs serving under the 12th Statement of Work will provide customized quality improvement to nursing homes and providers, serving rural communities and the most vulnerable populations. Through this body of work, CMS is focusing on results, protecting taxpayer dollars, and most importantly, ensuring the safety and quality of care delivered to every Medicare beneficiary," says HealthCentric Advisors.

     The QIN-QIOs will address nursing home and community coalition quality improvement in the following areas:

    • Improving Behavioral Health Outcomes – Including Opioid Misuse
    • Increasing Patient Safety
    • Increasing Chronic Disease Self-Management
    • Increasing the Quality of Care Transitions
    • Improving Nursing Home Quality
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  • MDS 3.0 Quality Measures (QM) User's Manual V13.0 (2/20)

    By CMS - February 05, 2020

    The MDS 3.0 QM User’s Manual V13.0 and Quality Measure Reporting Module Table V1.8 have been posted. The MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V13.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V12.1 has been moved to the Quality Measures Archive webpage.

    The Quality Measure Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module, with a unique CMS identification number specified for each QM. The Quality Measure Reporting Module Table V1.8 can be found in the Downloads section of this webpage and the Quality Measure Reporting Module Table V1.7 has been moved to the Quality Measures Archive webpage.

    Two files related to the MDS 3.0 QM User’s Manual have been posted:

    1. MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. MDS 3.0 QM User’s Manual V13.0 is included in the zip file titled User Manuals - Updated 01-21-2020 (ZIP).
    2. Quality Measure Identification Number by CMS Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. A unique CMS identification number is specified for each QM.

    The MDS 3.0 QM User’s Manual V13.0 and Quality Measure Reporting Module Table V1.8 have been posted. The MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V13.0 can be found in the Downloads section of this webpage and the MDS 3.0 QM User’s Manual V12.1 has been moved to the Quality Measures Archive webpage. The Quality Measure Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module, with a unique CMS identification number specified for each QM. The Quality Measure Reporting Module Table V1.8 can be found in the Downloads section of this webpage and the Quality Measure Reporting Module Table V1.7 has been moved to the Quality Measures Archive webpage.

    Two files related to the MDS 3.0 QM User’s Manual have been posted:

    1. MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. MDS 3.0 QM User’s Manual V13.0 is included in the zip file titled User Manuals - Updated 01-21-2020 (ZIP).
    2. Quality Measure Identification Number by CMS Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. A unique CMS identification number is specified for each QM.
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  • CMS to Provide Consumer Portal to Nursing Home Compare, Other Compare Sites (1/20)

    By CMS - January 27, 2020

    Making it Easier to Compare Providers and Care Settings on Medicare.gov

    CMS plans to improve online comparison tools to inform health care decisions

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  • AHRQ 2019 Chartbook on Patient Safety (10/19)

    By AHRQ - October 28, 2019

    This Chartbook on Patient Safety includes a section with results from the National Nursing Home Survey on Patient Safety:

    National Healthcare Quality and Disparities Report

    This Patient Safety chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (QDR). The QDR includes annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). This chartbook includes a summary of trends across measures of patient safety from the QDR and figures illustrating select measures of patient safety. A PowerPoint version is also available that users can download for presentations.

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  • CMS Dementia Care Resources Webpage (10/19)

    By CMS - October 25, 2019

    CMS has established a Dementia Care Resources page to provide information that was previously housed at the National Nursing Home Quality Improvement Campaign. Additional resources are available through the QIO program.


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  • Infection Control in Healthcare Personnel Guidelines (Part I) - Updated (10/19)

    By CDC - October 23, 2019
    Preventing the transmission of infectious diseases among healthcare personnel (HCP) and patients is a critical component of safe healthcare delivery in all healthcare settings. Today, CDC published Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services, an update of four sections of Part I of the Guideline for infection control in health care personnel, 1998 (“1998 Guideline“) and their corresponding recommendations in Part II:

    ·  C. Infection Control Objectives for a Personnel Health Service

    ·  D. Elements of a Personnel Health Service for Infection Control

    ·  H. Emergency-Response Personnel

    ·  J. The Americans With Disabilities Act

    The updated recommendations are aimed at the leaders and staff of Occupational Health Services (OHS) and the administrators and leaders of healthcare organizations (HCO) and are intended to facilitate the provision of occupational infection prevention and control (IPC) services to HCP and prevent the spread of infections between HCP and others. Additional updates to the 1998 Guideline are underway and will be published in the future. Updates in Part I include: 

    ·  a broader range of elements necessary for providing occupational IPC services to HCP;

    ·  applicability to the wider range of healthcare settings where patient care is now delivered, including hospital-based, long-term care, and outpatient settings such as ambulatory and home healthcare; and

    ·  expanded guidance on policies and procedures for occupational IPC services and strategies for delivering occupational IPC services to HCP.

    New topics include:

    ·  administrative support and resource allocation for OHS by senior leaders and management,

    ·  service oversight by OHS leadership, and

    ·  use of performance measures to track occupational IPC services and guide quality improvement initiatives.  

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  • Infection Prevention and Control: CDC Prevention Epicenters Program Innovation and Best Practices for PPE Use (10/19)

    By CDC - October 23, 2019

    Unrecognized spread of germs from healthcare personnel (HCP) contamination occurs every day in healthcare settings, posing a risk to patients and HCP alike. Recent Ebola virus outbreaks demonstrated that the potential for transmission of any pathogen in healthcare settings poses an immediate and serious threat. 

     Preventing the spread of germs in healthcare is essential to protecting the health of patients and HCP. This International Infection Prevention Week, the CDC Prevention Epicenters Program is pleased to announce a groundbreaking new journal supplement, “Personal Protective Equipment for Preventing Contact Transmission of Pathogens: Innovations from CDC’s Prevention Epicenters Program,” composed of 14 in-depth studies, published in this month’s Clinical Infectious Diseases. This research provides insights from recent personal protective equipment (PPE) work in U.S. healthcare settings. It provides evidence to improve routine use of PPE, and to prevent contact transmission of Ebola and other infectious diseases in healthcare settings.

    All healthcare settings can benefit from improvements in PPE use and design. PPE plays an important role in preventing the spread of infectious diseases in healthcare settings, but its optimal design and use need to be informed by dedicated research to achieve the reliability and effectiveness needed to protect patients and HCP. 

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