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Richter ShareSource Blog

Seeing the Connection Between Phase 3 Requirement of Participation and Quality Assurance and Performance Improvement (QAPI)


Note: This is the third blog in our multi-part blog series on the CMS Requirements of Participation.

Nov. 28, 2019 is quickly approaching, and with that will come Phase 3 of the Centers for Medicare and Medicaid Services’ (CMS’) Requirements of Participation. As part of this, a fully integrated QAPI program will be required on this date. This should come as no surprise since some of the QAPI components should have already been implemented by your long-term post-acute care (LTPAC) facility, as stated below. This requirement is not going away and should be implemented soon rather than later. 

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Topics: Qapi, QAPI Consulting

CMS Phase 3 Requirement of Participation: Compliance and Ethics Program


Note: This is the fourth blog in our multi-part blog series on the CMS Requirements of Participation.

The Compliance and Ethics section of the Centers for Medicare and Medicaid Services’ (CMS’) Requirements of Participation is a new section developed in response to a mandate under the Affordable Care Act that requires the operating organizations of skilled nursing facilities to have a compliance and ethics program that is effective in preventing and detecting criminal, civil and administrative violations and in promoting quality of care consistent with current regulations.

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Topics: QAPI Consulting

New Service: Corporate Clinical Navigator – the Extra Set of Hands Your SNF has Always Needed

Posted by Jennifer Leatherbarrow, RN, BSN, RAC-CT, QCP, CIC on Apr 13, 2018 8:01:00 AM

Long-term care rules and regulations have been changing at a fast and furious pace over the past few years. Often, changes can happen so quickly that it can be nearly impossible to train staff and update processes in time to stay current. We have seen this burden play out across all senior living facilities (SNFs), from independent homes to small and large chains alike.

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Topics: News & Events, Clinical Consulting, QAPI Consulting

QAPI Case Study: How a SNF Used QAPI to overcome decline of Activities of Daily Living (ADL) & customer satisfaction


This case study illustrates how one facility discovered how to utilize QAPI processes to overcome their specific ADL and customer satisfaction challenges.

Download our free e-book to find out how QAPI processes can enhance your facility here. 

Sunny Cove Nursing Home was informed by the state ombudsman that they had a reputation for discharging residents who have been unhappy with their care and overall outcomes. To address this, Jane Doe, DON, had her administrative nurses begin an investigation to determine if this allegation was credible.

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Topics: Clinical Consulting, QAPI Consulting

Implementing QAPI Program Planning and Processes – the Key to Helping LTPACs Overcome Challenges and Thrive

Posted by Jennifer Leatherbarrow on Mar 20, 2017 12:34:07 PM

Setting your goals is a vital part of the Quality Assurance/ Performance Improvement (QAPI) process. The first step entails establishing thresholds. In order to determine your thresholds, you must first collect the relevant data. When collecting data, it is important to ensure that the data is meaningful and not erroneous. Once the appropriate data is gathered, you will use that information to identify a threshold. The QAPI process must include this step for establishing an acceptable threshold, target or goal. Although benchmarks can be set for any threshold, clinical benchmarks should be set based on the consideration of standards of care or best practice for that specific benchmark. Such information can be obtained through professional organizations, research and databases within your industry. Another good source of information is the Centers for Medicare and Medicaid Services (CMS) website.

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Topics: Clinical Consulting, QAPI Consulting

Implementing Performance Improvement Plans as a Part of a QAPI Program

Posted by Jennifer Leatherbarrow on Mar 8, 2017 11:23:00 AM

Note: Do you want to learn more about Quality Assurance and Performance Improvement (QAPI), or have questions about how QAPI can help your LTPAC facility? Read our blog: What IS QAPI? Your Guide to the new LTPAC and Skilled Nursing Facility Standard for Quality Assurance and Performance Improvement.

What is a Performance Improvement Project in a skilled nursing or LTPAC facility?

A Performance Improvement Project (PIP) is a focused effort on a specific problem in one area of a long term post acute care (LTPAC) facility or agency, or for the entity as a whole. The process involves methodical gathering of data to bring additional clarity to facility issues or problems. The facility initiates a PIP to examine and improve care and/or services in areas that the facility has identified as areas of concern. Areas of concern will vary depending on the type of facility or agency and the distinctive scope of services provided.

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Topics: Clinical Consulting, QAPI Consulting

What IS QAPI? Your Guide to the new LTPAC and SNF Standard for Quality Assurance and Performance Improvement

Quality Assurance/Performance Improvement (QAPI) regulation was advanced as a part of the Affordable Care Act (ACA) of 2010, but the basic premise is not entirely new to long-term post-acute care (LTPAC) providers. The initiative expanded the existing Quality Assessment and Assurance (QAA) provision, thus “reinforcing the critical importance of how nursing facilities establish and maintain accountability…in order to sustain quality of care and quality of life for nursing home residents.” The Centers for Medicare and Medicaid Services has linked these initiatives to reimbursement, furthering the underlying tenet of value-based purchasing-paying for performance based upon resident-centric outcomes.

QAPI takes the QAA regulations further by incorporating root cause analysis and performance improvement guidelines. While Quality Assurance QA is the assessment of how well the facility is doing, Performance Improvement (PI) is the application of corrective actions and improvement of performance in a monitored and measured approach. The expectation is that LTPAC providers will continue to question and refine processes until optimal outcomes are met. The goal of QAPI is to improve processes in the delivery of care and ultimately improve patients’ quality of life, as well as overall quality of care.If you work in a Long Term Post-Acute Care (LTPAC) setting, you know that in our field the only constant is change. There is, however, one process that has been with us, in one form or another, for quite a long time. Until recently, Quality Assurance and Performance Improvement were two separate processes. These have since been streamlined into what we now know as the
QAPI (Quality Assurance/Performance Improvement) process.  Let’s start off with the CMS definition of QAPI:

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Topics: Regulatory Changes, Clinical Consulting, QAPI Consulting

QAPI Basics - The Five Elements and 12 Steps

If you work in a Long Term Post-Acute Care (LTPAC) setting, you know that in our field the only constant is change. There is, however, one process that has been with us, in one form or another, for quite a long time. Until recently, Quality Assurance and Performance Improvement were two separate processes. These have since been streamlined into what we now know as the QAPI (Quality Assurance/Performance Improvement) process.  Let’s start off with the CMS definition of QAPI:

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Topics: Clinical Consulting, QAPI Consulting