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Facility assessment, emergency preparedness and QAPI — a service delivery exercise

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Jason Elizaitis
Jason Elizaitis

Your post-acute/long-term care organization should be well on its way to developing its Facility Assessment, Emergency Preparedness Plan and written QAPI plan for compliance by November 2017. The best way to address these three new RoPs/CoPs is by transitioning your healthcare organization into one focused on service delivery.

These three rules build upon one another and have such a substantial amount of overlap, that if you haven't started on these initiatives yet, it is best to address them in a single exercise.

When you model their primary questions — “What do we have? (Facility Assessment); “How do we keep it running?” (Emergency Preparedness Plan); “How do we get better?” (QAPI) — they form the basis for a continuous improvement model, best done using a quantitative service delivery model.

In our facility assessment, we begin by assessing our people, places and things, forming the foundational knowledge and measurements we will later use in EPP and QAPI. In our emergency preparedness planning, we will determine how to maintain an excellent level of care even when our facility assessment numbers are jolted or misaligned.

Finally, via Quality Assurance and Performance Improvement (QAPI) we will continually measure and determine how we can best improve our services to provide the highest quality of care.

We are accustomed to viewing our organization as a series of individual parts which then combine to make the whole. We espouse a different approach, one of service delivery. At the center of the service delivery model lies the happy resident. Our happy resident receives a variety of services from us, a roof over his/her head, food, nursing care, as well as any other necessary care. Each of these “services” comprises a series of events that consume the people, places and things we addressed when creating our facility assessment. This series of events is known as the service chain. For example, in order to feed a resident, we need a proper environment, food, dietary staff, etc. …

As we develop our service chains, we measure a number of items: people; equipment; skill levels; facilities. These measurements form the foundation of the FA. The next step, EPP, is taking a deeper dive into how we manage disruption in our service chain. It is not by accident that the Hazard Vulnerability Analysis (HVA) appears in both the Facility Assessment and Emergency Preparedness Plan. We feel that although the primary focus of the Centers for Medicare & Medicaid Services is on larger scale events, we work to manage disruption at all levels of the service chain. It is more likely that we experience “bumps in the road” during daily operations than a large scale, low probability event. Now that we have put in a measurement and instrumentation system around our services, QAPI is an exercise in using those numbers to improve service. Are falls up? Did we use a new polish on our floors? Let's trace our service chain and see what is an area for improvement.

It is not by accident that these regulatory requirements are coming together and the best and most efficient way to excel is to treat them as one exercise. November is only a few months away, and while implementing these requirements as a single exercise may seem daunting, this is actually a more efficient and effective way to fulfill these requirements.

Jason Elizaitis is a Technology & Risk Consultant with CMS Compliance Group, Inc., an interdisciplinary compliance consulting firm. He can be reached at


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Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.