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.

  • Five-Star Technical User's Guide Plus Claims-Based Measures Appendix (1/21)

    By CMS - January 18, 2021

    CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Nursing Home Compare Web site features a quality rating system that gives each nursing home a rating of between 1 and 5 stars. Nursing homes with 5 stars are considered to have much above average quality and nursing homes with 1 star are considered to have quality much below average. This manual provides in-depth descriptions of the ratings and the methods used to calculate them. 

    On December 1, 2020 the Nursing Home Compare website was retired. It has been replaced by the new Care Compare website. Care Compare can be accessed at: (https://www.medicare.gov/care-compare/). The Provider Data Catalog (PDC) located at https://data.cms.gov/provider-data/ allows users to search and download the publicly reported data. While this Technical Users’ Guide has been revised to refer to Care Compare, there may be previously published materials or documents that refer to Nursing Home Compare and all prior references to Nursing Home Compare will now apply to Care Compare.


    January 2021 Revisions


    Health Inspection Rating Changes:

    Beginning with the January 2021 refresh, CMS resumed calculating the health inspection rating domain and began to use results from surveys that occurred after March 3, 2020. Additionally, focused infection control surveys are included in the rating calculation, with citations from these surveys counting towards the total weighted health inspection score (similar to how complaint survey citations are counted).

    These changes resulted in updates to the Special Focus Facility (SFF) program, including updates to SFF candidates, and facilities’ status for receiving an icon for noncompliance related to abuse. Specifically, updates to the health inspection data due to the incorporation of surveys occurring after March 3, 2020 and the updating of the complaint periods means that the abuse icon will be removed for facilities that no longer meet the abuse icon criteria based on more recent survey findings. Once facilities no longer meet criteria for the abuse icon, their health inspection rating will no longer be capped at two stars. More information on the abuse icon is found in the Health Inspection section of this document.

    Staffing Rating Changes:

    Beginning with the January 2021 refresh, facilities that did not report staffing for the November 14, 2020 deadline or that reported four or more days in the quarter with no registered nurse will have their staffing ratings suppressed. Their staffing ratings will show “Not Available” with the January, February, and March refreshes. Starting with the April 2021 refresh of Care Compare, when staffing data submitted by the February 14, 2021 deadline will be reported and used for the five-star ratings, nursing homes that do not report staffing data for October – December 2020 or that report four or more days in the quarter with no registered nurse will have their staffing ratings reduced to one star.


    Quality Measure Rating Changes:

    Quarterly updates of most of the quality measures (QMs) posted on Care Compare and used in the FiveStar Quality Rating System resumed with the January 2021 refresh. For the January 2021 update, CMS used data for July 2019- June 2020 for all of the measures that were updated. The two QMs that are part of the Skilled Nursing Facility Quality Reporting Program (Percentage of SNF residents with pressure ulcers/pressure injuries that are new or worsened and Rate of successful return to home and community from a SNF) will not be updated in January 2021.

    January 2020 addition: Technical specifications for claims-based measures

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  • Cross-Setting QRP Data Elements and Quality Measures: CMS Web-Based Training (1/21)

    By CMS - January 13, 2021

    From Data Elements to Quality Measures – Cross-Setting QRP Web-Based Training

    The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides a high-level overview of how data elements within CMS patient/resident assessment instruments are used to construct quality measures (QMs) across post-acute care (PAC) settings. The PAC settings included are those covered under the Centers for Medicare & Medicaid Services (CMS) Quality Reporting Programs (QRPs) for Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs) and Skilled Nursing Facilities (SNFs). Information covered will include a short review of the QRPs’ cross-setting quality measures (QM), how data elements feed into these cross-setting QMs, how QMs are calculated and appear on QM reports and how to access and use this data for quality improvement. 

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  • Five-Star: CMS to Resume Calculating Health Inspection and QM Ratings on Jan. 27, 2021

    By CMS - December 08, 2020

    Note that there will be a related update to the Five Star Technical User’s Guide by Jan. 15, 2021.

    Memo # QSO-21-06-NH

    Posting Date 2020-12-04

    Fiscal Year 2021


    The Centers for Medicare & Medicaid Services (CMS) is committed to being transparent with the public about changes in publicly reported information related to long term care facilities (i.e., nursing homes) through the COVID-19 public health emergency (PHE). Changes to the Nursing Home Compare Website and Five Star Quality Rating System:

    • CMS will resume calculating nursing homes Health Inspection and Quality Measure ratings on January 27, 2021.

    • CMS is completing its transition to the new Care Compare website.

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  • In 2 of 5 Evaluation Cycles, Half Billion Incentive Payment Distribution to Nursing Homes (12/20)

    By CMS - December 07, 2020
    On Dec. 7, 2020, the Health Resources and Services Administration (HRSA) operating under the U.S. Department of Health and Human Services (HHS), is announcing it will distribute $523 million in second round performance payments to over 9,000 nursing homes. These nursing homes are being rewarded for successfully reducing COVID-19 related infections and deaths between September and October. This announcement is the second of five evaluation cycles rewarding nursing homes for their performance reducing nursing home infection and mortality rates. Nursing homes will begin receiving payments December 9.

    Nursing Home Infection and Mortality Outcomes

    HHS found that between September and October, of the 13,251 eligible nursing homes, 9,248, or 69 percent, met the incentive program's infection control criteria. While less than the first cycle, the collective efforts of these nursing homes resulted in over 3,900 fewer infections relative to the rates seen in the communities where they exist. Against the mortality criteria, 9,128, or 68 percent of eligible nursing homes, achieved outcomes that met or exceeded the expected COVID-19 mortality rate for their facility.

    This announcement rewards nursing homes for a period in time. HHS recognizes COVID-19 is a fluid challenge and it continues to take a devastating toll on nursing homes stretched thin and disproportionately impacted due in part to factors such as their congregate setting and the existing vulnerabilities of older residents with comorbidities. This new round of incentive payments will bolster the $15 billion already distributed to nursing homes in both Targeted and General Distribution PRF funding. Recipients may use this funding to acquire additional personal protective equipment or other efforts to help slow the spread of COVID-19.

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  • LTCSP Initial Pool Care Areas UPDATED (12/20)

    By CMS - December 01, 2020

    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.


    Effective Date: 11/21/2020

    In the RI, RO, RR and RRI care areas and probes:

    • Under infections care area, update the probes for the respiratory infection and infections (not UTI, PU, or respiratory) areas 
    • Add a new Transmission-Based Precautions care area
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  • Adverse Events in Italian Nursing Homes During the COVID-19 Pandemic (11/20)

    By AHRQ - November 26, 2020

    Lombardo FL, Salvi E, Lacorte E, et al. Front Psychiatry. 2020

    Long-term care and skilled nursing facilities are particularly vulnerable to COVID-19 infection; this increased risk may present other threats to patient safety. This survey of nursing homes in Italy found that one third of facilities reported at least one adverse event during the early weeks of the COVID-19 pandemic. Adverse events were more likely to occur in nursing homes with higher bed capacities, increased use of psychiatric drugs, and use of physical restraints. These findings can inform nursing homes creating mitigation plans.

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  • Higher Incidence of Adverse Events in Isolated Patients Compared With Non-isolated Patients: A Cohort Study (11/20)

    By AHRQ - November 24, 2020
    Jiménez-Pericás F, Gea Velázquez de Castro MT, Pastor-Valero M, et al. BMJ Open. 2020;10(10):e035238.

    Isolation for infection prevention and control, albeit necessary, may result in unintended consequences for patients (e.g., less attention, suboptimal documentation and communicationhigher risk of preventable adverse events [AEs]). This prospective cohort study found that the incidence of all AEs and preventable AEs were significantly higher in isolated patients compared to non-isolated patients, primarily caused by healthcare-associated infections. These findings highlight the importance of training and safety culture when providing care to patients in isolation, particularly given the expanded use of isolation due to the COVID-19 pandemic.

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  • CDC Infection Prevention and Control Assessment (ICAR) Tool for Nursing Homes Preparing for COVID-19 UPDATED (11/20)

    By CDC - November 23, 2020

    Infection Control Assessment and Response (ICAR) tools are used to systematically assess a healthcare facility’s infection prevention and control (IPC) practices and guide quality improvement activities (e.g., by addressing identified gaps).

    This tool is an update to the previous ICAR tool for nursing homes preparing for COVID-19. Notable changes as of November 20, 2020 include:

    • Additions to reflect updated guidance such as SARS-CoV-2 testing in nursing homes
    • Increased emphasis on the review of Personal Protective Equipment (PPE) use and handling
    • Addition of sections to help guide a video tour as part of a remote TeleICAR assessment or in-person tour of a nursing home
    • Addition of an accompanying facilitator guide to aide with the conduction of the ICAR and create subsequent recommendations for the facility

    This updated ICAR tool is a longer but more comprehensive assessment of infection control practices within nursing homes. Due to the addition of example recommendations to aid the facilitator during the process of conducting an ICAR, the facilitator guide version of the tool appears even longer. Facilitators may decide whether to use the tool in its entirety or select among the pool of questions that best fit their jurisdictional needs and priorities as part of quality improvement efforts.

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  • Residents With Acute Respiratory Symptoms? CDC Testing and Management Considerations When SARS-COV-2 and Influenza Co-Circulate (11/20)

    By CDC - November 23, 2020
    This document contains practices that should be considered when SARS-CoV-2 and Influenza viruses are found to be co-circulating based upon local public health surveillance data and testing at local healthcare facilities.
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  • CMS COVID-19 Nursing Homes Best Practices Toolkit and New QIN-QIO Virtual Assistance UPDATED (11/20)

    By CMS - November 15, 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 (updated 11/22/20) 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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  • CMS Will Retire Nursing Home Compare Tool and Fully Transition to Care Compare on December 1 (11/20)

    By CMS - November 15, 2020
    CMS will retire the original Compare Tools on December 1st. Use Medicare.gov’s Care Compare to find and compare health care providers.

    In early September, the Centers for Medicare & Medicaid Services (CMS) released Care Compare on Medicare.gov, which streamlines our eight original health care compare tools.  Since then, you’ve had the opportunity to use and familiarize yourself with Care Compare while having the option to use the original compare tools, too.  You’ve also been able to share feedback from a survey directly on Care Compare and we’ve received lots of great feedback so far.

    The eight original compare tools – like Nursing Home Compare, Hospital Compare, Physician Compare – will be retired on December 1st, ending this transition period. If you haven’t been using Care Compare, we urge you to:

    ·  Use Care Compare on Medicare.gov and encourage people with Medicare and their caregivers to start using it, too. Go to Medicare.gov and choose “Find care”.

    ·  Update any links to the eight original care tools on your public-facing websites so they’ll direct your audiences to Care Compare.

    Care Compare offers a new design that makes it easier to find the same information that’s on the original compare tools. It gives you, patients, and caregivers one user-friendly place to find cost, quality of care, service volume, and other CMS quality data to help make informed health care decisions.

    Now, instead of having to search through many compare tools, with just one click on Care Compare, you’ll find easy-to-understand information about nursing homes, hospitals, doctors, and other health care providers.

    Please remember that when we retire the 8 original compare tools, you will still be able to find information about health care providers and CMS quality data on Care Compare, as well as download CMS publicly reported data from the Provider Data Catalog on CMS.gov.  Fully transitioning to these tools does not change how CMS measures quality. In addition, we’ll continue to make improvements to Care Compare and the Provider Data Catalog based on stakeholder and consumer feedback now and in the future. 

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  • HHS Sends Incentive Payments to Nursing Homes Curbing COVID-19 Deaths / Infections (10/20)

    By HHS - October 29, 2020

    The U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), is announcing it will distribute approximately $333 million in first round performance payments to over 10,000 nursing homes. These nursing homes are being recognized for demonstrating significant reductions in COVID-19 related infections and deaths between August and September. This announcement illustrates how complementing relief payments with outcome-based payments help to yield positive results in improving quality and infection control in nursing homes.

    "These $333 million in performance payments are going to nursing homes that have maintained safer environments for residents between August and September," said HHS Secretary Alex Azar. "We've provided nursing homes with resources and training to improve infection control, and we're rapidly providing incentives to those facilities that are making progress in the fight against COVID-19."

    Nursing homes have been particularly hard hit by this pandemic. In response, the Trump Administration has employed a number of strategies to protect nursing home residents and slow the spread of COVID-19. In addition to General Distribution funding through the Provider Relief Fund program, HHS dedicated almost $5 billion in targeted funding to nursing homes in May.  HHS then announced another $5 billion opportunity in August. Of this amount, HHS distributed $2.5 billion in early September to help nursing homes with upfront COVID-19-related expenses for testing, staffing, and personal protective equipment (PPE) needs. Another $2 billion is being used to create an incentive program divided into five performance cycles. This performance-based payment structure will reward nursing homes for keeping new COVID-19 infection and mortality rates among residents lower than the communities they serve, as analyzed against CDC data.

    Nursing Home Performance-Based Results

    Today, HHS is announcing that in the first round of the incentive program, which compared data from August to September, 10,631 nursing homes, or over 77 percent of the 13,795 eligible, met the infection control criteria. Overall, these nursing homes contributed to 5,000 fewer COVID-19 infections in nursing homes in September than in August. Against both the infection control and mortality criteria, 10,501 nursing homes, or 76 percent, qualified for payments and contributed to 1,200 fewer COVID-19 related nursing home deaths between August and September.

    Nursing homes will receive September quality incentive payments next week and will have four more opportunities to receive additional incentive payments.

    HHS is encouraged by the promising September results but recognize this virus is dynamic and there is still opportunity for continued improvement. Safeguarding nursing home residents from the perils of this devastating pandemic will remain a top priority for HHS.

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  • SNF QRP October Refresh 2020: Six New Measures Publicly Reported (10/20)

    By CMS - October 29, 2020

    The October 2020 refresh of SNF QRP data is now available on Nursing Home Compare (NHC), as well as the Nursing homes including rehab services web pages within Care Compare (CCXP) and Provider Data Catalog (PDC).

    The data are based on quality assessment data submitted by SNFs to CMS from Quarter 1 2019 through Quarter 4 2019 (01/01/2019 –12/31/2019); and the annual update of the claims-based measures data from Quarter 4 2017 – Quarter 3 2019 (10/01/2017 – 9/30/2019).

    Starting in October 2020, six additional SNF QRP measures will be publicly reported on NHC, CCXP and PDC:

    ·  Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury,

    ·  Drug Regimen Review Conducted with Follow-Up for Identified Issues – PAC SNF QRP,

    ·  Application of IRF Functional Outcome Measure: Change in Self-Care (NQF #2633),

    ·  Application of IRF Functional Outcome Measure: Change in Mobility (NQF #2634),

    ·  Application of IRF Functional Outcome Measure: Discharge Self-Care Score (NQF #2635), and

    ·  Application of IRF Functional Outcome Measure: Discharge Mobility Score (NQF #2636).

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  • MDS 3.0 Quality Measures (QM) User's Manual V14.0 (10/20)

    By CMS - October 20, 2020

    The MDS 3.0 QM User’s Manual V14.0 has been posted. The MDS 3.0 QM User’s Manual V14.0 contains detailed specifications for the MDS 3.0 quality measures and includes a Notable Changes section that summarizes the major changes from MDS 3.0 QM User’s Manual V13.0. The MDS 3.0 QM User’s Manual V14.0 can be found below, grouped with other Skilled Nursing Facility (SNF) and Nursing Home user’s manuals in a zip file titled Users-Manuals-Updated-10-19-2020.  The zip file titled User Manuals - Updated 01-21-2020 (ZIP) containing the MDS 3.0 QM User’s Manual V13.0 has been moved to the Quality Measures Archive webpage.

    Five files have been posted:

    1. MDS 3.0 QM User’s Manual V14.0 (MDS-3_0-QM-USERS-MANUAL-v14_0.pdf) contains detailed specifications for the MDS 3.0 quality measures, as well as the Quality Measure Reporting Module Table that documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. MDS 3.0 QM User’s Manual V14.0 is available under the Downloads section of this webpage.
    2. Nursing Home Compare Claims-based Quality Measure Technical Specifications (Nursing Home Compare Claims-based Measures Tech Specs.pdf) contains detailed technical specifications for all nursing home quality measures.
    3. Nursing Home Compare Quality Measures Technical Specifications Appendix (APPENDIX - Claims-based measuresTechnical Specifications.pdf) contains tables and appendices related to the Nursing Home Compare Claims-based Quality Measures.
    4. Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual V3.0 (SNF Measure Calculations and Reporting User's Manual V3.0_FINAL_508C_081419.pdf) contains detailed specifications for all SNF QRP Quality Measures.
    5. SNF QRP Measure Calculations and Reporting User’s Manual Version 3.0.1 (SNF-QRP-QM-Users-Manual-V3_0_1-Addendum-Change-Table.pdf) contains appendices for the SNF QRP Measure Calculations and Reporting Manual V3.0, including a risk adjustment appendix and Hierarchical Condition Category (HCC) crosswalks.
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  • SNF QRP COVID-19 PR Tip Sheet Updated (10/20)

    By CMS - October 01, 2020
    An updated version of the SNF COVID-19 PR Tip Sheet that was posted on September 8, 2020, is now available. The purpose of this Tip Sheet is to help providers understand CMS’ public reporting strategy for the PAC QRP in the midst of the COVID-19 public health emergency (PHE).  This Tip Sheet explains the CMS strategy to account for CMS quality data which were exempted from public reporting due to COVID-19, and the impact on CMS’ Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data on the Nursing Home Compare website refreshes.  
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