We’re more than halfway through the Conditions of Participation webinar series. So far, we’ve covered the CoPs basics, plan of care changes, and QAPI programs for home health. During Webinar 3, Arlene Maxim, RN, Vice President of Program Development for Quality in Real Time (QIRT) delved into the complexities of newly required programs for QAPI and infection prevention and control.
In her presentation, Arlene also referenced an excellent article by home care and hospice care consultant Mary McGoldrick, MS, RN, CRNI about preventing and controlling infections spread via clinicians’ nursing bags using the “bag technique.” While nursing bags transport our clinical tools, they can also transport pathogenic microorganisms into the patient’s home, even transferring them from one home to another. This article presents practical guidelines for management of the nursing bag.
The CoPs series has shared a lot of helpful information on complex topics. Remember, you can review videos online at any time. To watch Webinars 1-5 visit kinnser.com/cops.
Highlights from Webinar 3:
- Your Board must review and approve at each step, evaluating the
- entire QAPI process
- Will look for very clear documentation as to how compliance has
- been achieved in this area
- Performance improvement to be conducted at least annually
- Surveyors may have preconceived notions of what they are
- looking for in QAPI. Make it easy for them!
- Be sure you can show your data collection and data use
- Reports to reflect agency service and operations relative to:
- The scope of services
- Complexity of services
- Past performance
Keys to Overall Success
- Read the Final Rule
- Form an agency policy committee made up of administration, management, and staff.
- Perform a GAP analysis- discover what needs to be worked on first and make assignments.
- Implement programs, not just policies:
- Infection prevention and control
- Ensure each program has written guidance.
- Review current QAPI efforts to identify what components can be utilized in the efforts to prepare for individual QAPI.
- Evaluate education/staff development and ensure comprehensive and all-inclusive:
- Board of Directors/executive team
- Patient care team
- Administrative staff
- Supportive staff
- Start reviewing data that is available
- CASPER reports, STAR ratings, PEPPER reports
Frequently Asked Questions, Answered by Arlene Maxim, RN:
Question: Can you clarify exactly which QAPI elements need to be ready by January 13 and which need to be ready by July 13? What does our agency need to do between those two dates?
Answer: Great question! After our webinar last Thursday, October 26, a draft of the interpretive guidelines (IGs) was issued that give us some clarity on this question. The draft guidelines indicate that “beginning January 13, 2018 agencies must conduct performance improvement projects. The HHA [home health agency] should have one performance improvement project either in development or ongoing or completed each calendar year.” This is the only time in the entire QAPI section of the draft interpretive guidelines that a date is even mentioned. There is no “six month” preparation of data (as we expected). I’m certain that comments on the draft interpretive guidelines will request clarification on this.
If you are an agency that is accredited, it would appear they will determine if you met the standard. However, if you are not accredited and this is your first application of QAPI, it appears that the surveyors will expect that your plan is laid out, that your board is involved in selecting criteria and oversight, and that you plan at least one meeting per year to discuss the program in detail. Page 29 of the draft interpretive guidelines says “the governing body ensures that the agency systematically collects data to measure various aspects of quality of care; the frequency of data collection; how the data will be collected and analyzed; the agency uses the data that is collected to assess quality and stimulate performance improvement.”
On page 30 of the draft interpretive guidelines, the January 13, 2018 date is mentioned with an interpretation indicating that “the HHA should have one performance improvement project either in development, ongoing or completed each calendar year.”
My recommendation is that you plan carefully, document fully, and begin data collection immediately.
Page 28 of the draft interpretive guidelines presents another subject you should note –– the need to have a strong infection control, investigation, and prevention program as part of QAPI. Be sure your infection control and prevention program is well written and identifies exactly what data you will be collecting.
Question: You mentioned a role of QAPI manager. Could you give more details about the prerequisites for this role, what its responsibilities are, and whether or not it is a full-time position?
Answer: The need to have a full time position for a QAPI manager will depend on the size of the agency. In the draft interpretive guidelines, they do not identify a “QAPI manager” as a role that needs to be created. However, someone in your organization will need to take ownership of the program. Someone at the home health agency will need to be responsible for collecting, tracking, and reporting data. If the agency is small enough, perhaps the role could be part of that of clinical manager, but be very careful that the staff member is qualified in data collection and infection control since this will be one area where the surveyor will spend significant time and will be vulnerable for deficient practice.
Question: It sounds like the governing board has big responsibilities regarding QAPI. Who is on the board?
Answer: The board of directors is also known as the governing body. CMS defines it this way: “A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program.”
The board, then, would be persons who will accept the fiscal and legal responsibility for the Board positions. Many agencies enlist accountants, physicians, attorneys, and owners. Whomever you identify must commit to considerable amount of time with added QAPI responsibilities.
Question: Are there specific agency roles that must serve on the board?
Answer: No. There are no identified credentials for board members; it comes down to who is willing to make the necessary commitment.
Question: Are there agency roles that may not serve on the board?
Answer: No. However, I am very concerned when agencies get overzealous and want staff on their board — i.e. their receptionist or office manager, etc. I recommend you keep board membership to fewer than five. During votes, it can be very difficult to reach agreement with large numbers of members. Keep in mind that being a board member is a heavy responsibility.
Question: What are the prerequisites to serve on the board?
Answer: Simply put, board members agree to full fiscal, legal, and QAPI responsibilities and take action for compliance, infection control, etc. It is quite a commitment.
Question: How many people must be on the board?
Answer: Your agency’s policy dictates the number of people on your board. My recommendation is fewer than five. Some folks have asked if a board can include just one person. Note that the definition of the governing board in the CoPs (§ 484.105 in the rule) uses the plural word “persons,” not the singular “person” or the indefinite “person or persons.” Because the governing board will be a focus on upcoming surveys, I will not be surprised if they enforce the “persons” definition in the future.
Question: How often must the governing board meet?
Answer: At least yearly. But again, this depends on your policy and the size of your agency. With the specificity of board member commitments (QAPI and infection control), the frequency may need to increase.
Question: How frequently should the governing board review QAPI?
Answer: At least yearly. But again, this will depend on the size of your agency, the activity in QAPI, and your policy.
Question: How do we decide which quality indicators to track?
Answer: Look carefully at your CASPER reports, STAR ratings, HHCAHPS, and PEPPER to determine where your outliers are, as well as your adverse events. Use best practices in determining your improvement standards.
Question: What things will surveyors look for in a QAPI program?
Answer: They will be looking at your policies and plan. Use the reports mentioned above to find areas in which you can show improvement. Remember, this is a quality assessment (QA) and performance improvement (PI) process — QA+PI=QAPI. In your policies and procedures, carefully identify exactly how you will accomplish both. Don’t forget to include compliance (fraud and abuse issues) and infection control in your improvement plan. I have given you a QAPI self assessment handout that should give you some indication of items to be addressing.
Question: What will be the top things on their checklist?
Answer: Surveyors will definitely look for “procedures for and frequency of measurement and analysis of indicators.” They will also be looking for “indicators related to improved outcomes, including the use of emergent care services, hospital admissions and readmissions; and how the HHA [home health agency] takes action to prevent and reduce medical errors.” In a sense, the surveyor’s “checklist” will be determined by the specific performance improvement projects that your agency focuses on.
Question: What are the requirements for Performance Improvement Projects (PIPs)? Do they have to be patient-related, or could something like staff retention be a PIP?
Answer: Your agency is responsible for identifying PIPs. If staff retention is a problem that has an effect of quality patient care, then yes that might be something to consider. The Standard 484.65(c) indicates PIP activities must focus on high risk, high volume, or problem prone areas; and should consider the incidence, prevalence, and severity of problems in those areas and lead to an immediate correction of any identified problem that directly or potentially threatens the health and safety of patients. The PIP must track adverse patient events, analyze their causes, and implement preventive actions. So one thing you might want to think about is addressing medication lists with correct doses, names, etc. Surveyors will be closely monitoring clinical record listings of medications and matching them to the in-home list. This is an area we see out of compliance often. This is also a “potential for harm” that could lead to an immediate jeopardy finding during survey.
Question: You mentioned the need for an infection control manager. Is this a new role? Is it a full-time position? Can the infection control manager have other roles as well? For example, can they also be the clinical manager?
Answer: I think I answered that above in a similar question regarding QAPI managers. CMS does not specify that a staff member is to be appointed as an “infection control manager.” The task must be completed, so this could be part of another role (clinical manager), but keep in mind the clinical manager has a lot going on in their job description. Someone must take ownership for the role and responsibilities for infection control and prevention.
Question: What data sources are appropriate for measuring quality indicators? Some, like HHCAHPS and Home Health Compare have long lag times, which make them months out of date by the time you receive them. Does QAPI make more real-time data tools — like those in Kinnser and PPS Plus — even more important?
Answer: Absolutely! Those tools created by Kinnser and PPS Plus will be invaluable in creating QAPI programs and gathering data in real time. You should use also the other reports mentioned, since surveyors will be looking at them, too. It will be important to identify what data you are using and how the data has changed.
Question: Is a medical director required under the new CoPs?
Answer: No, a medical director is not required under the new home health CoPs. Some licenses or accreditations may require medical directors, but the home health CoPs do not. I keep hearing that this is a new requirement, but a medical director is not now and has never been a CoP requirement in home health.
Watch Now — Webinar 3: Focus on QAPI Plans and Infection Identification, Prevention, and Control
Your CoPs Reading List:
To prepare for Webinar 4, we invite you to review the following pre-class reading materials. Here’s our shortlist of must-read CoPs resources:
- FAQs: Home Health’s New Role: The Clinical Manager
Get answers to your questions about the new clinical manager role required in the CoPs. This tip sheet is ready to download and share with your team.
- Blog: 5 Hard Truths About the New Home Health Conditions of Participation
Agencies must accept that CoPs compliance requires significant time and resource investments. Read to get a high-level view of how the new CoPs will impact your business.
- Blog: 3 Emergency Preparedness Resources Your Agency Needs Now
The November 15 is the deadline for having emergency preparedness plans in place. These essential resources will help your agency comply with CMS’s new requirements.