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DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Plan Review QAA Review – This review should occur at the end of the survey, after completion of investigation into all other requirements. However, identification of systemic concerns to be reviewed during the QAA review should begin with Offsite Preparation and occur throughout the survey
Offsite: Make note of concerns identified during offsite preparation, which will be further investigated during the survey (repeat deficiencies, ombudsmen concerns, and complaints/facility-reported incidents). These represent possible systemic issues, which if validated during the survey, should be cited under the relevant outcome tag, and incorporated into the QAA review for investigation
Team Meetings: During end of day team meetings, the survey team discusses potential systemic issues or shared concerns for further investigation, or those that have been validated for incorporation into the QAA review
Were any offsite concerns (repeat deficiencies, ombudsman concerns, and complaints/facility-reported incidents) validated during the survey? Were new systemic concerns validated (concerns which will likely be cited at pattern or widespread, or substandard quality of care) during the survey? Has more than one surveyor identified and validated the same concern? Note: Disclosure of documents generated by the QAA committee may be requested by surveyors only if they are used to determine compliance with QAA regulations
QAA Committee: Determine through review of the information requested by the TC during Entrance, an interview with the QAA contact person and review of QAA records: Does the facility have a QAA committee that meets at least quarterly? Does the QAA committee include the required members? • Director of Nursing Services; • Medical Director; • Nursing home administrator, owner, board member, or other individual in a leadership role; and • Two other staff members
For every systemic issue identified and validated during the survey, determine if the QAA committee also has identified the issue and made a “Good Faith Attempt” to correct it. To determine this, do the following: a) interview the QAA contact person, and b) review evidence in order that will answer the following questions: Is the QAA committee aware of this issue? Is the issue a high risk, high volume, or problem-prone issue that the committee should know about? Has action been taken to correct this issue since it was identified? Is the QAA committee monitoring to ensure the corrective action has been implemented and the correction is being sustained?Form CMS 20058 (2/2017) Page 1 DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES Quality Assessment and Assurance (QAA) and QAPI Plan Review Is the issue corrected? That is was the facility in substantial compliance as of the first day of the survey because of the corrective action taken? If corrected, consider citing the related tag as Past Noncompliance
Has the QAA committee revised its corrective action based on its monitoring and evaluation? If No to any of the above, interview the staff responsible for conducting QAA activities to determine how the facility is able to identify and correct its own quality deficiencies any time they occur throughout the facility. Select from among the following questions, or ask your own: How does the QAA committee know when an issue arises in any department? How does the QAA committee know when a deviation from performance or a negative trend is occurring? Is there a mechanism for staff to report quality concerns to the QAA committee? How does the QAA committee decide which issues to work on? How does the QAA committee know that corrective action has been implemented? How does the QAA committee know when improvement is occurring? How long will the QAA committee monitor an issue that it has corrected? How is this decided? Interview staff in various departments to determine whether they know how to bring an issue to the attention of the QAA committee
1. Did the QAA committee develop and implement appropriate plans of action to correct identified quality deficiencies? Yes No F867 2. Does the QAA committee consist of the minimum, required members? Yes No F868 3. Does the facility have a QAA committee that meets at least quarterly? Yes No F868 4. Does the QAA committee put forth Good Faith Attempts to identify and correct its own quality deficiencies? Yes No F865QAPI Plan ReviewReview the QAPI Plan to ensure it includes policies and protocols describing how the facility will identify and correct its own quality deficiencies
Does the QAPI plan have policies/protocols describing how it will: Track and measure its performance? Establish goals and thresholds for performance measurement?Form CMS 20058 (2/2017) Page 2 DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES Quality Assessment and Assurance (QAA) and QAPI Plan Review Identify and prioritize deviations from performance and other problems and issues? Systematically investigate and analyze to determine underlying causes of systemic problems and adverse events? Develop and implement corrective action or performance improvement activities? Monitor and evaluate the effectiveness of corrective action/performance improvement activities? 5. Does the facility have a QAPI plan containing the necessary policies and protocols describing how they will identify and correct their quality deficiencies? Yes No F865Form CMS 20058 (2/2017) Page 3
Form CMS 20058 (2/2017) Page 1 . DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Quality Assessment and Assurance …
The program also assesses the efficiency and effectiveness of the internal audit activity and identifies opportunities for improvement. All internal audit activities, regardless of industry, sector, or size of audit staff — even those outsourced or co-sourced — must maintain a QAIP that contains both internal and external assessments.
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CMS implements quality initiatives to assure quality health care for Medicare Beneficiaries through accountability and public disclosure. CMS uses quality measures in its various quality initiatives that include quality improvement, pay for reporting, and public reporting.
An internal audit activity must obtain an external assessment at least every five years by an independent reviewer or review team to maintain conformance with the Standards. Internal assessments are ongoing, internal evaluations of the internal audit activity, coupled with periodic self-assessments and/or reviews.