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Is your facility fully prepared to meet the requirements of Quality Assurance and Performance Improvement (QAPI) Phase 3? The new set of requirements goes into effect November 28, 2019. This blog post serves as a resource for you in addressing QAPI Phase 3 requirements.

In summary, QAPI takes a systematic, comprehensive and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers. The goal of QAPI is to improve care for individuals and improve health for populations, while reducing per capita costs in the healthcare delivery system.

QAPI Phase 3

CMS proposed a one-year delay on implementing some of the QAPI Phase 3 requirements. However, a final ruling has not been determined. Therefore, we suggest proceeding with implementing all Phase 3 action items that are a part of the following sections.

Note: For further in-depth CMS provided QAPI Phase 3 information click here, or watch the RehabCare QAPI Phase 3 seminar here. 

  • 483.12: Freedom from Abuse, Neglect and Exploitation
    • In order to provide protections for each resident in your facility, you will need to integrate your QAPI freedom from abuse, neglect and exploitation plans.
  • 483.21: Comprehensive Person-Centered Care Planning
    • Services provided or arranged by your facility must be culturally competent and trauma-informed.
  • 483.25 Quality of Care
    • Provide training to staff related to trauma-informed care to ensure that residents who are trauma survivors are provided care that eliminates or mitigates triggers that may cause re-traumatization.
  • 483.40: Behavioral Health Services
    • In order to provide great care for residents with mental and psychosocial disorders, including those with a history of trauma and PTSD, your facility must develop and implement a process to assess facility staff competencies and skills to provide care for these residents.
  • 483.60: Food and Nutrition Services
    • Designate a Director of Food and Nutrition Services that meets the requirements of the state law. This ensures there is sufficient and qualified staff with the appropriate competencies and skillset to carry out food and nutrition services.
  • 483.70: Administration
    • Determine a process and frequency for the facility administrator to implement policies and report on facility management and operations.
  • 483.75: Quality Assurance and Performance Improvement
    • Maintain a quality assessment and assurance committee consisting of, at a minimum, the Director of Nursing, Medical Director or a designee, three other members of the facility’s staff and the infection preventionist.
  • 483.80: Infection Control
    • Designate at least one preventionist who is responsible for the facility’s Interprofessional Collaboration (IPCP).
  • 483.85: Compliance and Ethics Program
    • The operating organization for each facility must have in operation a compliance and ethics program that meets the requirements of QAPI, including written compliance and ethics standards, policies and procedures.
  • 483.90: Physical Environment
    • Equip a call system at each resident’s bedside to allow residents to call for staff assistance that relays the call directly to a centralized staff work area.
  • 483.95 Training Requirements
    • Develop, implement and maintain an effective training program for all new and existing staff at your facility.

For more information about how RehabCare can help your facility, call 502.596.7640.

By RehabCare