What the NAC Needs to Know About QAPI

Posted By: Jessica Kunkler, MA
Post Date: 03/21/2018

The Centers for Medicare & Medicaid Services (CMS) requirement that facilities have a fully implemented QAPI program by November 28, 2019, means that it’s time to take QAPI plans from paper into practice. As the NAC, you have a lot to contribute to the process, especially when it comes to understanding how your facility’s quality ratings, such as Five-Star, come to be and can be improved to contribute to the success of your organization.

CASPER reports can be an important tool in developing Performance Improvement Projects to improve quality ratings, according to Maureen McCarthy, RN, BS, RAC-MT, QCP-MT, President of Celtic Consulting. But they can only help if you use them in time, before the data hits the Five-Star ratings. As McCarthy says, “Five-Star reports are water under the bridge.” Alternatively, resident preview reports available through CASPER tell you which residents will be triggering, which gives you an opportunity to review the information for accuracy, to identify something larger going on, and even to correct erroneous information.

McCarthy offers the example of pressure ulcers as a condition that your facility staff can look at and follow closely in CASPER reports. “If you know that you have 12 people triggering for a pressure ulcer in a quarter, first go back and look in the medical records. If you see a prevalent coding problem, you know right away that you have an education problem.” If it’s not a coding issue, it’s time for a root-cause analysis, stresses McCarthy. First, verify that nursing assessments are being done. Next, is the staging correct? Last, is there something more?

McCarthy continues with the example of prevalent pressure ulcers where the coding, assessments, and staging were all being done correctly. However, after the nurse aides completed body audits, they were not consistently turning and positioning. Why was this happening? It turned out that most of the pressure ulcers were occurring on one unit, where the staff was consistently working short. On this unit, the acuity was just too high for all the necessary work to get done. On a 30-bed unit, 21 residents required a Hoyer lift assistant and 23 were totally dependent in eating. This was causing aides to call in sick when assigned to that specific unit. The solution, after a full investigation, was to disperse some of the acuity from this single unit.

CASPER reports should be used on a monthly basis to monitor how your facility is trending for continuous quality improvement, according to McCarthy. You can hear more from Maureen McCarthy about how to use specific reports to improve quality indicators, at her upcoming session at the AANAC Conference, April 11–13 in Las Vegas, Nevada. During this session, you will learn how routine, federally reported data, along with data monitored in day-to-day operations in the nursing home, can support the success of your facility’s QAPI implementation program.


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