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 Seeks TEP Nominations for Claims-based SNF QRP Measure on Healthcare Associated Infections

    By CMS - January 18, 2019

    Project Title: Development and Maintenance of Quality Measures for Skilled Nursing Facility Quality Reporting Program (SNF QRP)

    Dates:

    The TEP nomination period opens on January 21, 2019 and closes on February 15, 2019. Please submit all nomination materials by the closing date.

    Project Overview:                                                                                       

    The Centers for Medicare & Medicaid Services (CMS) has contracted with RTI International to develop and maintain quality measures for the SNF QRP. The contract name is Development and Maintenance of Symptom Management Measures (HHSM-500-2013-13015I). As part of its measure development and maintenance process, CMS asks measure developers to convene groups of stakeholders and experts who contribute direction and thoughtful input to the measure developer during measure development and maintenance.

    Project Objectives:

    Healthcare-associated infections are an important public health and patient safety issue. Under the Quality Priority of “Making Care Safer by Reducing Harm Caused in the Delivery of Care” is the Meaningful Measure Area of Healthcare Associated Infections. To focus on the high priority domain and fill an important gap of quality measurement in this area, this project is aimed to develop a claims-based measure of healthcare-associated infections in skilled nursing facilities.  

    The purpose of this TEP is to inform the direction and development of a claims-based measure of healthcare-associated infections in skilled nursing facilities.

    TEP Objective:

    ·        To obtain input on the options for a claims-based measure of healthcare-associated infections in skilled nursing facilities

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  • CASPER Reporting User’s Guide for MDS Providers UPDATED (1/19)

    By QTSO - January 18, 2019
    Provides information and instructions pertaining to CASPER Reporting, including accessing Final Validation Reports.
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  • Five Star Preview Reports Available; Help Line Open 1/21 - 1/25

    By QTSO - January 18, 2019

    The Five Star Preview Reports will be available on January 17, 2019. To access these reports, select the CASPER Reporting link located on the CMS QIES Systems for Providers page. Once in the CASPER Reporting system, select the 'Folders' button and access the Five Star Report in your 'st LTC facid' folder, where st is the 2-character postal code of the state in which your facility is located and facid is the state-assigned Facility ID of your facility.

    Nursing Home Compare will update with January's Five Star data on January 23, 2019.

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  • KAER Toolkit: 4-Step Process to Detecting Cognitive Impairment and Earlier Diagnosis of Dementia (1/19)

    By National Nursing Home Quality Improvement Campaign - January 15, 2019
    KAER Toolkit: 4-Step Process to Detecting Cognitive Impairment and Earlier Diagnosis of Dementia from the GSA Workgroup on Cognitive Impairment Detection and Earlier Diagnosis. The KAER toolkit provides an extensive collection of evidence-based, practical and easy-to-use guidance for primary care providers, including clinically-relevant and scientifically supported measurement instruments for detecting cognitive impairment and links to clinical practice guidelines for conducting diagnostic evaluations for dementia.
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  • CMS Wants Feedback by Feb. 1 on SPADEs (Potential New Standardized MDS Elements)

    By CMS - January 13, 2019
    On November 27th, 2018, on behalf of the Centers for Medicare & Medicaid Services (CMS), the RAND Corporation hosted a meeting in which they presented an overview of results from the National Beta Test of candidate standardized patient assessment data elements (SPADEs) and answered questions from attendees. Presentation materials, a transcript of the session, and Frequently Asked Questions related to the presentation are available on CMS' IMPACT Act Downloads and Videos page. CMS invites feedback on this presentation and on the SPADEs tested in the National Beta Test. Please submit input by sending an email to SPADEForum@rand.org. Feedback is requested by February 1, 2019. A verbatim comment summary report will be posted on the CMS website, but CMS will not be responding to comments.
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  • Register for March 12 Dementia Care & Psychotropic Medication Tracking Tool Call (1/19)

    By CMS - January 13, 2019
    During this call, gain insight on the Dementia Care & Psychotropic Medication Tracking Tool, a free, publicly available electronic tool that facilitates a structured approach to tracking preference-based care and psychotropic medication use among residents living with dementia. Also, learn about a recently released Nursing Home Staff Competency Assessment toolkit. Additionally, CMS provides updates on the Phase 3 Requirements for Participation from the Reform of Requirements for Long-Term Care Facilities final rule and the progress of the National Partnership to Improve Dementia Care in Nursing Homes. A question and answer session follows the presentations.
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  • Register for Free Jan. 24 QIN-QIO Webinar: All Cause Harm Prevention in Nursing Homes Applying Strategies from the New CMS Change Package (1/19)

    By QIN-QIOs - January 03, 2019
    One-third of SNF residents experience an adverse or temporary harm event, and the majority of those are preventable. As part of CMS’s focus on raising awareness of nursing home safety and to support safer nursing home care across the nation, CMS and the Quality Innovation Network National Coordinating Center released a new resource: a Change Package to prevent all cause harm in nursing homes. The Change Package is a compendium of successful practices of high-performing nursing homes, illustrating how they prevent harm while honoring each resident’s rights and preferences. 

    Please join us to learn more about the development of the Change Package and how you can use it to improve the quality of life and quality of care for those living in nursing homes and other long-term care settings. Registration is required
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  • CDC Pneumococcal Vaccination App: PneumoRecs VaxAdvisor (1/19)

    By CDC - January 03, 2019
    CDC launched an app to help vaccination providers quickly and easily determine which pneumococcal vaccines a patient needs and when.
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  • National Partnership to Improve Dementia Care in Nursing Homes: Antipsychotic Medication Use Data Report (1/19)

    By CMS - January 03, 2019

    The National Partnership to Improve Dementia Care in Nursing Homes is committed to improving the quality of care for individuals with dementia living in nursing homes. The National Partnership has a mission to deliver health care that is person-centered, comprehensive and interdisciplinary with a specific focus on protecting residents from being prescribed antipsychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individual’s need. The Centers for Medicare & Medicaid Services (CMS) promotes a multidimensional approach that includes; research, partnerships and state-based coalitions, revised surveyor guidance, training for providers and surveyors and public reporting. 

    CMS is tracking the progress of the National Partnership by reviewing publicly reported measures. The official measure of the Partnership is the percentage of long-stay nursing home residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington's Disease or Tourette’s Syndrome. In 2011Q4, 23.9 percent of long-stay nursing home residents were receiving an antipsychotic medication; since then there has been a decrease of 38.9 percent to a national prevalence of 14.6 percent in 2018Q2. Success has varied by state and CMS region, with some states and regions having seen a reduction of greater than 40 percent. 


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  • FY 2021 SNF QRP Program Data Collection & Final Submission Deadlines (12/18)

    By CMS - December 18, 2018

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

     

    This table provides the data collection time frames and final submission deadlines for the Fiscal Year (FY) 2021 Skilled Nursing Facility Quality Reporting Program (SNF QRP). The first column 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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  • LTCSP Initial Pool Care Areas UPDATED (12/18)

    By CMS - December 18, 2018
    This includes four documents, one each for: record review, resident interview, resident observations, and resident representative interview. They walk through what the surveyors investigate/ask related to each care area during the initial pool to help determine which residents they will choose for in-depth investigations in the final sample. In other words, these screening tools trigger surveyors to either investigate further or not investigate further.
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  • NNHQIC All-Cause Harm Prevention in Nursing Homes Change Package (12/18)

    By National Nursing Home Quality Improvement Campaign - December 07, 2018

    Change Package to prevent harm related to medication adverse events, other adverse events, infection, and abuse,and neglect for nursing home residents.

     

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  • Nursing Home Compare Claims-based Measures Technical Specifications Plus Appendix Updated (12/18)

    By CMS - December 07, 2018

    Nursing Home Compare Claims-based Measures Technical Specifications -Update December 2018  plus Appendix


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  • NNHQIC Sets Dementia Care & Psychotropic Medications Goal (11/18)

    By NNHQIC - November 26, 2018

    The National Nursing Home Quality Improvement Campaign's new quality goal to improve care for individuals living with dementia focuses on knowing the person, building on strengths, filling days with positive moments, and proactively addressing unmet needs.

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  • CMS Offers Networking, Technical Assistance, Funding as Part of CMP Reinvestment Project (11/18)

    By CMS - November 26, 2018

    Breakthrough Communities and Technical Assistance

     A Breakthrough Community is a voluntary and customized health care improvement program that is based on a model designed by the Institute for Healthcare Improvement (IHI). Its goal is to achieve “breakthrough” improvement in nursing homes that may be experiencing challenges in one of two program areas: reducing adverse events and/or improving dementia care.

    In Breakthrough Communities, nursing homes work with their peers to test interventions that will lead to improvement in quality of life and quality of care for residents of nursing homes.

    If you are interested and want to apply, please email CMP-info@cms.hhs.gov.

    Technical Assistance To improve dementia care, CMS funds and provides one-to-one Technical Assistance (TA) to a selection of nursing homes through the CMPRP. One-to-one TA will be customized to your nursing home to address unique barriers in improving quality of life and quality of care for residents with dementia.

    The purpose of one-to-one TA is to provide education and support to nursing homes’ quality improvement processes, including root cause analysis and the development of a performance improvement plan framework for the improvement of dementia care and ensuring the appropriate use of antipsychotic medications.

    If you are interested and want to apply, please email CMP-info@cms.hhs.gov.

    Civil Money Penalty (CMP) Funds

    About Civil Money Penalty (CMP) Funds

    A CMP is a monetary penalty the Centers for Medicare & Medicaid Services (CMS) may impose against nursing homes for either the number of days or for each instance a nursing home is not in substantial compliance with one or more Medicare and Medicaid participation requirements for long-term care facilities.

    A portion of CMPs collected from nursing homes are returned to the states in which CMPs are imposed. State CMP funds may be reinvested to support activities that benefit nursing home residents and that protect or improve their quality of care or quality of life.

    What CMP Funds Can Be Used For

    CMP funds may be used for (but not limited to) the following:

    ·        Assistance to support and protect residents of a facility that closes or is decertified

    ·        Time-limited expenses incurred in the process of relocating residents to home and community-based settings or another facility when a facility is closed or downsized pursuant to an agreement with the state Medicaid agency

    ·        Projects that support resident and family councils and other consumer involvement in assuring quality care in facilities

    Facility improvement initiatives, such as joint training of facility staff and surveyors, or technical assistance for facilities implementing quality assurance and performance improvement programs

    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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