On January 13th,
CoPs Breakdown on the New QAPI Regulations
the rules for CoP's Quality Assessment and Performance Improvement regulations changed. Section 484.65 QAPI has replaced sections 484.16 (Group of Professional Personnel) and 484.52 (Evaluation of the agency’s program). The new section does a great deal to highlight the responsibilities of the agency's executive team and expects the governing bodies to focus on technology concepts like data- driven indicators to identify, track, and measure quality initiatives for high risk, high volume or safety issues.
The program includes 5 standards:
• Program Scope 484.65 (a)
• Program Data 484.65 (b)
• Program Activities 484.65 (c)
• Performance Improvement Projects 484.65 (d)
• Executive Responsibilities 484.65 (e)
Agencies are required to develop a data-driven QAPI program with measurable improvement indicators. The organization must measure, analyze, and track quality indicators including a patient’s adverse events, as well as other signs of performance to assess processes, services, and operations. However, it is not enough to just create the indicators. Agencies must use data to provide evidence that the improvement has led to improved health outcomes (ex: reduced hospitalizations, ED visits), safety and quality of care for patients.
The QAPI program must utilize quality indicator data, including measures derived from OASIS that CMS has reported, to assess the quality of care provided to the patients and identify, prioritize, and manage opportunities for improvement. The QA efforts, including data collection, should focus on high-priority safety and health conditions. Like the program scope, data collected should support the quality measures and identify opportunities for improvement.
Agencies will need to focus on those areas of past performance which have proven problematic for the agency over time or areas where there was clear evidence of poor patient outcomes as well as high risk and high volume.
The QAPI activities should include incidence, prevalence, and severity of problems in those areas. So that preventative actions and mechanisms can be implemented, agencies must track and analyze activities over time to ensure sustained improvements. Management should immediately correct any issues identified that directly or potentially threaten the health and safety of patients.
Performance Improvement Projects
The QAPI program requires that agencies performance improvement projects be conducted annually, at a minimum. The plan should reflect each agencies unique scope, complexity, and past performance. There should be clear documentation of the QAPI projects including the reason for conducting these projects and the measurable progress achieved.
The agency’s governing body must define, implement, and maintain a program for quality improvement and patient safety that is ongoing and agency-wide.
The governing body for each agency is responsible for ensuring the QAPI reflects the complexity of the organization and its services, including contract and arrangement, are focused on indicators related to improved outcomes. They must also approve the frequency and level of detail in data collection. The governing body should establish clear expectations for patient safety and address issues in performance across the spectrum of care including the prevention and reduction of medical errors.
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New CoPs and Your Agency: Patient-Specific, Individualized Care, and QAPI- Take a Deep Breath
An overview of the Conditions of Participation (CoP) revisions
It has been decades since the Conditions of Participation for Home Health have been significantly revised. The last time it was attempted, Bill Clinton was President.
The new rule expands patient rights, care planning, and care coordination standards. The changes require much education and planning. It requires the agency governing body to take responsibility for the new required QAPI program.
The theme throughout the rule and CMS response to comments is quality, individualized care and patient engagement. They stated they expect, “patient-centered, data-driven, outcome-oriented processes that promote high quality care at all times for all patients.”
An overview of the CoP revisions are highlighted below. For a full review see the 375 page final rule, effective as of July 13, 2017 or contact Select Data. A focus, per CMS, is to improve the quality of home health care services for patients and to strengthen patient rights.
CMS expects patients to be made aware of their rights in a form that can be understood by the patient and their representative (if they have one). The written patient rights forms must be given prior to any care being administered. If a patient does not wish their non-legally appointed representative to have a copy of the rights, the agency must note that fact in the clinical record.
If a patient has a legally appointed representative, they must receive a copy of the rights prior to the patient receiving any care. In addition, the patient is to be made aware of the name of the clinical manager and their business phone number so clinical questions may be directed to that person.
In addition, CMS is requiring that home health agencies be given the name and contact information of the agency administrator so complaints may be made directly to them.
CMS is seeking “a more holistic patient assessment.” The intent is to develop a more complete understanding of the patient that “will enable HHAs and physicians to develop a plan of care that is more comprehensive and more likely to achieve desired outcomes.” To achieve this goal, CMS has some new requirements that include:
- Adding a psychosocial, functional, and cognitive status assessment to the overall comprehensive assessment of the patient.
- Assessing and identifying the patient’s strengths, goals, and care preferences including progress toward goal achievement stated in the clinical record.
- Assess the patient’s primary caregivers
- Identify the patient’s representative
- Assess the patient’s risk for hospitalization/rehospitalization, require for ALL HHA admissions.
The individualized care plan must include “patient specific measureable outcomes which the HHA anticipates would result from its implementation.”
The agency must provide written instructions regarding care, tasks, or schedules so they have a tool to reference between visits. CMS did not restrict the agencies on the written instructions. Calendars for schedules could be used as well as checklists, or handwritten notes.
CMS wants agencies to use patient strengths and engage the patients so they are actively involved in their care. The belief is that the likelihood of positive outcomes is greater.
Care coordination is the driver toward quality with CMS stressing a focus on the patient as an active participant on the interdisciplinary team. It is obvious that the team is being encouraged to develop very patient-specific plans of care playing to each patient’s strengths and level of involvement.
CMS expects each visit note to identify what skill was completed, but what skilled service is needed for the patient. They also expect progress toward goal attainment to be well documented.
Quality Assessment and Performance Improvement
This new 484.65 CoP, Quality Assessment and QAPI will replace two CoPs, namely Group of Professional Personnel and Evaluation of the Agency Program.
CMS expects HHA to identify their own agency-specific risk areas with a focus on high risk, high volume problem areas. The program is to be agency wide and the Governing Body must approve details of areas chosen, dates/frequency of data collection, and review results. Because this program will take time to be fully operational, CMS is giving this CoP and extension of time, making it required January 13, 2018.
Agencies will be responsible for documenting the number of QI projects undertaken coupled with reasons chosen and results of each project.
Agencies must institute a strong surveillance, identity, prevention, and intervention infection control program. Education is expected to be seen throughout this program establishment.
Skilled Professional Services
Combining the CoPs Skilled Nursing Services, Therapy Services, and Medical Social Services, CMS is stressing an ongoing interdisciplinary assessment of the patient. They identify an expectation of development and evaluation of the POC in partnership with the patient, their representative (if any), their caregivers, and the HHA personnel. The professional services are expected to provide counseling, patient education, prepare clinical notes, communicate with the physician, participate in the QAPI program and participate in HHA sponsored inservice trainings.
Of course there remains specific direction regarding each service entity such as an RN supervising and LPN/LVN. Those types of items have not changed.
Home Health Aide
This new CoP has nine specific standards. A significant change allows an agency to accept a certified nurses aide for a home health aide position provided they completed their training and competency and remain in good standing on the state registry. Of course, any specific training necessary for the aide to perform safely in the home with a particular patient is the responsibility of the HHA.
It was stressed that the aide is a member of the interdisciplinary team. They are to have training as to how to document and communicate with/to patients, family members, and other members of the team.
There is also a new requirement that an annual onsite visit be performed at a location where a patient is receiving care to assess and observe care delivery. Also, under the new CoPs, home health aides may receive assignments by an RN or any other skilled professional also delivering care; PT, OT, or S/LP.
These new CoPs signal a shift from problem-focused care, that CMS acknowledged had “inherent limits” to quality focused care. The new CoPs actively involve the patient, capitalizing on their strengths, uses tools and communication methods the HHA identifies as best for the patient.
CMS is encouraging HHA to establish a meaningful QAPI program that identifies agency specific issues rather than mandating prescriptive dictated problems to address.
Though NAHC has sent a letter to CMS advising a delay until July, 2018 to institute the new CoPs, agencies should not delay in establishing a team to conduct a gap analysis, identify needs, and institute education programs for all CoPs mandated for July 13, 2017. They must also initiate planning for the indepth QAPI program that will take the extra time given by CMS to be fully functional.
For further information or consulting needs, contact Select Data at 1.800.332.0555