CHAPTER 23 | Quality Assurance and Performance Improvement 373


observe gaps between the facility’s written policy, staff performance, and the regulation, a deficiency can be issued to the nursing home. The nursing home will then need to submit an improvement plan, called a plan of correction (POC), within a defined time frame. The POC must be submitted to and accepted by the survey agency for that state. The POC may also be referred to as 2567, which is the Statement of Deficiencies and Plan of Correction designated by the CMS. The QAA committee is expected to oversee the POC develop- ment and implementation for deficiency tags issued.


Deficiencies and Federal Tags


For each regulation, there is an assigned deficiency tag that can be issued if the surveyor deems that the standards of that regulation are substandard or absent. Each requirement for participation in the Medicare and Medicaid program has an assigned deficiency tag number for noncompliance. Surveyors issue tags des- ignated by the letter F for quality-of-care deficiencies (F-tags). Several F-tags are directly related to QAPI (refer to Box 23.5).9


Root Cause Analysis, Performance Improvement Projects, and Plan- Do-Study-Act


After any adverse incident, near miss, or potential problem is identified, an investigation should be


initiated and a root cause analysis should be per- formed to identify what happened and why and to determine what changes need to be made. Root cause analysis is a structured team process that assists in identifying underlying factors or causes for an adverse event or near miss. Near misses can be strong indicators of unseen process problems. Understanding the contributing factors and root causes for a system failure can help develop actions that are sustainable corrections. Root causes are circumstances that, if eliminated, would prevent recurrence of the adverse event. Root cause analysis is how the hidden reasons for an adverse event are discovered. After the root cause analysis is completed, the next step is to begin a PIP. The PIP is a concentrated effort focused on a particular problem that involves gathering information systematically to clarify the issues or problems identified by the nutrition profes- sional, then intervening to make improvements. PIPs are integral to QAPI and specifically stated as part of the requirement. An interdisciplinary team may be convened to complete a PIP that develops out of an identified nutrition or dining services problem and may then be disbanded after the goal is achieved and a sustainment plan is operationalized. The interdis- ciplinary team includes facility members from varied departments and service areas who perform the task or are affected by or have knowledge of the process or problem in question.


Box 23.5 F-Tags Directly Related to Quality Assurance and Performance Improvement9 F-tag


Description F865 F867 F868


Intended to ensure that long-term care facilities (including multiunit chains) implement a comprehensive quality assurance and performance improvement (QAPI) program that addresses all the care and unique services a facility provides.


Intended to ensure that facilities obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety.


Intended to ensure that the quality assessment and assurance committee responsibilities include identifying and responding to quality deficiencies throughout the facility, and oversight of the QAPI program when fully implemented. Additionally, the committee must develop and implement corrective action and monitoring to ensure performance goals or targets are achieved and revise corrective action when necessary. The committee should be composed of staff who understand the characteristics and complexities of the care and services delivered by each unit or department.


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