Video Discription |
This includes new and revised guidance for the following F-tags:
F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt): Adds new requirements for the QAPI plan and program to ensure that nursing homes (including multi-unit chains) implement a comprehensive QAPI program that addresses all of the care and unique services that a facility provides. Changes include the following:
-Adds definitions for governing body, indicators, QAPI, and QA.
-Details minimum program requirements, including the need to:
Address all care and management systems.
Include clinical care, quality of life, and resident choice concerns.
Use the best available evidence to define measure indicators of quality and facility goals that reflect care processes and facility operations that are demonstrated to predict desired outcomes for residents.
Reflect the complexities, unique care, and services that the facility provides.
-Defines governorship and leadership requirements for the program.
-Provides examples of when disclosure of information may be needed for surveyors to determine compliance.
-Instructs surveyors to use the QAPI and QAA Review facility task plus the Appendix PP guidance to investigate concerns and determine compliance.
-Updates the facility elements of noncompliance.
F866 (QAPI/QAA Data Collection and Monitoring): Relocates the requirements from this tag into F867 (QAPI/QAA Improvement Activities).
F867 (QAPI/QAA Improvement Activities): Add requirements that address how a facility obtains feedback, collects data, monitors adverse events, identifies areas for improvement, prioritizes improvement activities, implements corrective and preventive actions, and conducts performance improvement projects. This includes the following:
Updates multiple definitions, including adverse event, high-risk areas, incidence, indicator, medical error, near miss, prevalence, systematic, and systemic.
Addresses the role of feedback as a data source.
Requires that the facility:
Collect and monitor data reflecting its performance.
Address how data will be identified, as well as the frequency and methodology for collecting and using data from all departments.
Establish priorities for performance improvement activities that focus on resident safety, health outcomes, autonomy, choice, and quality of care, as well as high‐risk, high‐volume, and/or problem‐prone areas.
Have policies and procedures in place for developing, monitoring, and evaluating performance indicators, including how and with what frequency that will be done.
Have systems in place and implement actions to improve performance, including implementing corrective actions, measuring the success of these actions, and tracking their performance. This should include changes at the systems level to prevent quality of care, quality of life, or safety problems.
Develop and implement policies and procedures addressing the use of systematic approaches to assist in determining underlying causes of problems that impact larger systems (e.g., root cause analysis, reverse tracker methodology, or healthcare failure and effects analysis).
Track medical errors and adverse resident events; analyze the cause of identified errors or events; implement corrective actions, including the education of staff, residents, resident representatives, and family members; and monitor to ensure that the desired outcome has occurred and is maintained.
Conduct at least one improvement project annually that focuses on high‐risk or problem‐prone areas, identified by the facility through data collection and analysis.
Instructs surveyors to use the QAPI and QAA Review facility task plus the Appendix PP guidance to investigate concerns and determine compliance.
F868 (QAA Committee): Identifies the infection preventionist as a required active member of the facility’s QAA committee who must report on the infection prevention and control program (e.g., facility process and outcome surveillance, occupational communicable diseases, or the antibiotic stewardship program), as well as on infections identified under the program (e.g., healthcare‐associated infections). The IP should attend each QAA meeting, and if they can’t, another staff member should report on their behalf. |