Andrew Kramer, M.D., Providigm

The long-awaited QAPI regulations are finally in effect. Facilities now have until November 28, 2017 to create their QAPI plan and present it to state surveyors. Under the new rule, they are also responsible for conducting a facility assessment that is directly linked to the establishment of the QAPI program.

While evaluating organizational capacity is a common practice for nursing facilities, documentation for the assessment has not been traditionally required or accessible to surveyors. However, under the new QAPI regulation, surveyors will have access to the facility assessment as well as to the QAPI plan.

The facility assessment reflects the administration’s evaluation of the resident population, staff competency, and resources required to meet the highest practicable physical, mental and psychosocial needs of the residents. A facility’s number of performance improvement projects (PIPs) will be represented in the facility assessment. The following three elements should be included for an effective assessment.

The assessment identifies areas for needed improvement: The new QAPI regulation is an opportunity to customize performance improvement activities that specifically meet the organization’s goals. The assessment will help identify gaps in staff competencies and the resources currently available to meet patient needs produce better outcomes. To help identify these areas, the assessment must take into account the number of current residents and resident capacity, staff competency required to provide care, ethnic or cultural factors that may potentially affect quality of care, and the facility’s resources, including buildings, vehicles and equipment. Administrators should document actions taken to address the gaps between what is currently available and what is needed.

The assessment addresses services advertised versus services provided: In 2014, the healthcare community was shaken when a resident sued a retirement community for falsely advertising skilled nursing services. The facility assessment can help prevent such a situation by identifying any discrepancies in what services the facility advertises versus what is actually offered.  Upon assessment completion, proper caution should be taken to review the facility’s marketing materials to ensure they accurately reflect the level of care and services the facility provides.

The assessment must be revised annually: As quality priorities change, a facility must update their assessment annually to identify any additional resources required to competently care for residents, such as medical and non-medical equipment and proper education for caregivers.

It is important that facilities take the assessment period seriously. Failure to conduct an appropriate facility assessment can result in poor patient care due to lack of staff competency and/or insufficient resources.

Once the facility has completed their assessment, they can proceed with writing their QAPI plan.

Andrew Kramer, M.D., is the CEO and founder of Providigm LLC