Regulatory Activity–July 2021

There continue to be more and more citations for QAPI.  The CMS regulations on QAPI are so prescriptive, these deficiencies automatically result in a directed plan of correction and largely with a mandatory involvement of Telligen and hired consultant for a 6-month oversight period.  These deficiencies are being cited as an overlay of sorts when a facility receives a deficiency indicating a failure of a clinical management system (e.g. wound prevention, fall interventions, or nutrition/hydration) or when a facility has received information through resident/family feedback and has not been able to remedy the problem.  In other words, if there should have been a root cause analysis and efforts to address the issue with a full understanding of all that could be driving it, you are looking at a QAPI deficiency.  Of course, documentation is our only way of proving we have done this work, and in some cases, the deficiency is cited when the Performance Improvement Plan (PIP) does not illustrate it was actually worked.  Even though COVID restrictions and guidance continue to place an undue burden on our teams, the State enforcement is ramping up to its previous level again and begs our attention.  Now is a great time to leverage the QAPI process for your own assurance that you are self-improving and controlling the quality agenda in your building.

Given the delay in recertification surveys, most facilities are experiencing complaint investigations alongside their annuals.  These can be a symptom of visitors seeing their loved ones for the first time in many months or simply reexamining their role as the resident’s advocate.  Here are some other areas at risk for regulatory attention based upon current trends:

Pressure ulcer prevention, management, and identification §  Quality check dressing changes

§  Competency evaluations for agency personnel (C.N.A.s and Nurses)

§  Shift-to-shift rounds for C.N.A.s

Deficiencies resulting from unresolved resident concerns, such as staffing, bathing preferences, dignity, or abuse reporting §  Talk to your residents – weekly rounds by resident advocates

§  Talk to their loved ones – regular update calls that are not triggered by a problem notification

§  Tighten Concern/Grievance resolution

§  Document and publicize Resident Council issues and how they are helping to improve the facility (connect them to QAPI)