In my previous article about the Nursing Home Quality Assurance and Performance Improvement guidelines (QAPI), published by the Centers for Medicare and Medicaid Services (CMS), I discussed my delight in learning that this is a Requirement of Participation (RoP) that really works! QAPI’s evidenced-based development has created a robust set of guidelines that can address concerns and fix problems long-term. Properly implemented, QAPI is of real benefit to senior living and long-term care facilities, and can significantly increase residents’ quality of care.


Now that the Phase 2 deadline has passed, it’s time to focus on fine tuning QAPI implementation. Under the revised mega rules a robust QAPI program is a must, and facilities are expected to achieve a new level of quality. CMS indicates that the design and scope of QAPI must “…be ongoing and comprehensive, dealing with the full range of services offered by the facility…” and utilize “…the best available evidence to define and measure goals.” Ultimately, the goal is not to meet minimum standards – it is to continually aim higher.


My clients across the country are asking “where do we start?”, “do we scrap what we are currently doing and start all over?”, and, most importantly, “how do we find time to do all this?” The good news is that QAPI isn’t entirely new, even though the emphasis from CMS and the surveyors is different. The first thing to do is conduct a Gap Analysis/ Self-Assessment of your current QA Program. CMS has provided a QAPI self-assessment tool to assist centers with this process. This tool can be used at the beginning of QAPI implementation and for annual or semiannual assessments. It should be completed with “input from the entire QAPI team and organizational leadership.”


This assessment process is “meant to be an honest reflection of your progress with QAPI.” The temptation will be to rush through it so you can get QAPI started - resist. I cannot stress enough the importance of building a strong foundation for your QAPI program – enhancements can be added later, and continuously, to demonstrate the good faith efforts you are taking to meet the RoP. Take the time to honestly assess what you’ve got right now, and avoid excusing failures and shortchanging successes.

Some questions to consider:

Does your QAPI program…

  • Track, investigate, and try to prevent recurrence of adverse events?
  • Compare quality to other centers?
  • Set targets for quality?
  • Receive complaints/concerns? Demonstrate investigation and process improvement based on complaints/concerns?
  • Include feedback from direct care staff, residents and resident representatives?
  • Incorporate staff in a shared QAPI mission? Is training available to all staff on QAPI strategies and tools?
  • Balance a safe environment with resident choice?
  • Build on residents’ goals for health, quality of life, and daily activities?
  • Strive to achieve better outcomes?
  • Use data to identify quality problems and opportunities for improvement, and then set priorities for action?
  • Develop Performance Improvement Project (PIP) teams with specific charters?
  • Perform Root Cause Analysis (RCA) to get to the REAL reason for the problem?
  • Develop a system of promoting and asking for continuous feedback?
  • Monitor systems and processes to sustain and promote a ‘quality culture’ for continuous improvement?
  • Have a written/documented plan that includes steps necessary to identify, implement, and sustain improvements in all departments?


In the senior-living industry, we have a lot on our plate every day, and may find ourselves wondering how we will ever get this accomplished. It is helpful to think of quality as a journey, rather than a destination. The first steps on the journey are to establish a quality culture that engages and empowers staff at all levels to identify quality opportunities, gaps in processes, and methods to correct processes; and establishes ongoing monitoring to ensure goals and outcomes are being achieved. It will require some extra effort, but in the long-term, I believe QAPI will increase the quality of service throughout our industry, thereby improving the lives of our residents, and therefore well worth the effort.

Teresa Remy, DSc, MHA, LNHA, BSN, RN, RAC-CT, CDP, QCP, has nearly 35 years of experience working in healthcare and is the Director of Clinical Services at LeaderStat. Her areas of expertise include the entire continuum of care from Acute Care to every aspect of Post-Acute Care such as Sub-acute, Skilled Nursing, Residential Care/Assisted Living, Home Care, Hospice/ Palliative Care and Private Duty. 

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