04/14/2022

Survey Tip of the Week: QAA/QAPI

The Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) plan review is a mandatory task, part of the Long-Term Care Survey Process (LTCSP). This task is to take place at the end of the survey; however, with enough time to investigate and follow up on potential concerns. Surveyors are instructed that prior to interviewing the facility staff about the QAA program, the surveyor is to review the facility rates for MDS indicators, prior survey history, facility-reported incidents, and complaints. The surveyor is to review the facility’s QAPI plan. The surveyor is to have a list of concerns the facility should be aware of (e.g., harm or IJ, pattern or widespread issues, or concerns identified by two or more surveyors).

LeadingAge Ohio encourages facilities to provide the manager who will be assigned to participate in the quality assurance interview with the surveyor the Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Plan Review LTC Pathway. The LTC pathway instructs surveyors to ask the following questions:

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.

LeadingAge Ohio encourages facilities to utilize the Long-Term Care Survey Process and the LTC survey pathways to monitor for compliance. The survey pathways can be found on the CMS Nursing Home webpage, under the download section, and within the zip file called LTC Survey Pathways.

For more information about the citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the May 11 call at 10:00AM.

LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you’d like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.