QAPI – Are you Struggling to be Compliant with the new Conditions of Participation

To have a compliant and effective QAPI program in order to avoid deficiencies in 484.65 G640 / and the other ten G tags, you first must understand what a QAPI program requires.

Quality programs have always been meant to help your organization ensure it is improving patient care/outcomes and maintaining compliance with all regulations. A good Quality program – QAPI – should never be “busy work”, but should be an agency wide program that helps you understand where your agency stands, and then gives you opportunities to improve. QAPI is a key component of a well-run organization. It not only assists in minimizing risk, but it also increases an agency’s quality and efficiency. A good QAPI program should be incorporated into everyday operations and can lessen the day-to-day challenges!

But How do you Comply to the QAPI Condition?

The CoP (Condition of Participation) is very specific and prescriptive, which should help agencies to develop their programs.

There are key elements that an agency must include and address in their QAPI program, including: reflecting the complexity of the org and services, involving all services, indicators focusing on improving outcomes, including emergent care and rehospitalizations, integrating infection prevention and preventing/reducing medical errors.
A key part of a Quality program is to identify what your high volume, high risk, problem prone areas are. When looking at the complexity of your services, a high risk and problem prone area may be IV therapy services or pediatric services. Perhaps you do a high volume of lab draws, wound care, therapy services – although they are relatively routine procedures, there can be areas in which to improve due to the high volume/ problem prone nature. By evaluating your HHA program and selecting high volume, high risk and problem prone areas, you are able to begin to identify the Quality Indicators you will include in your program.

In addition, it is necessary to include outcomes from the CASPER OASIS Outcome Reports and Home Health Compare, particularly those in which you are statistically significant to the nation, state, and/or your agency prior period. The selected outcomes would also be written as Quality Indicators.

Development of the QAPI Plan

Agencies often lack the formality of a Quality program, causing deficiencies. That is, an audit tool may be utilized to review records for a certain area, such as wound care, however, there is no quality indicator written, and/or the audits are not analyzed objectively, with an action plan to improve the results. An example of a Quality Indicator and action plan for wound care is:

The QAPI coordinator will review 20 percent of patient records with wound care quarterly to focus on following physician orders with a goal of 90 percent compliance.

Audit tool criteria would include wound care physician orders are updated as necessary. SN visit notes document wound care performed accurately to the physician orders.

Example: Ten records were reviewed in a quarter with the compiled results at 60 percent. The goal was not achieved; therefore, a specific action plan will be developed and implemented in order to improve the results.
Findings example: Six of ten records reviewed indicated that physician orders for wound care were not followed.

What do you do with the Data?

Many agencies perform a lot of audits, gather a lot of data, but then do not do the most important steps in a QAPI program.

Analyzing, Trending and Developing Action Plans

By utilizing specific criteria on audit tools and compiling the results, it becomes simple to analyze and trend results in order to develop action plans. Often agencies write very generic action plans instead of specific steps to follow. Action plans often include education to staff on particular topics, process and/or policy change, and, of course, the QAPI monitoring.

Action Plan Example:

  1. Wound care expert in-service and competency performed, with focus on following current physician orders.
  2. Joint supervisory home visits made with all nurses on wound care patients by next quarter.
  3. Process change – On patients from ‘567 Wound Care Clinic’, the Clinical Manager will contact SN on the same day with order changes.
  4. Process change – On patients from ‘567 Wound Care Clinic’, the Clinical Manager will contact SN on the same day with order changes.

In QAPI, it is important for indicator results to improve and then sustain that improvement. An annual QAPI calendar is an easy way to monitor results and progress as well as to share with staff and Governing Body:


Indicator Freq Goal Jan Feb Mar
Clinical Record Review q 90% 82% 88%
Wound Care q 90%  60% 90%
Improving Pain q 79% 65% 72%
Fall Reduction q <10%  15% 9%
Infection Surveillance q <2% 1%  3%


Whenever an indicator is lower than the goal or has significantly varied over the time periods of collection, it is important to update the action plan. Be more specific than simply stating to “continue to monitor”. Drill down to the items that you will perform this time period in order to improve and sustain.

QAPI Projects

You may find that a deficiency is high risk, high volume and problem prone.  It may be widespread, effecting many services as well as office and field staff.  Or the results of an indicator are not improving.  These examples could be candidates for a Performance Improvement Project.

The projects can involve performing a root cause analysis, where a task force of stakeholders drills down to the challenges involved.  Often communication is key – between clinicians, office staff, physicians and patients/ caregivers.  And, very often processes and policies need to be revised.

Example: IV therapy can involve many parties, including physicians, home infusion, pharmacy, supply delivery, nursing, patient and caregiver – who requires education on high risk procedures.

QAPI SUCCESS – Get Everyone in your Agency Involved

Having a large QAPI team and rotating them every six months to a year is a great way to get all staff involved.  The team will brainstorm on action plans, indicators, audit tools, etc.  Assign team members to cover parts of the action plan, example: clinical record reviews, education, and process development.

Your agency will improve in many ways when your staff is involved in QAPI, including having better understanding of regulations, improved documentation, communication and patient care.

QAPI Never Stops! 

Indicators may be able to be discontinued once you find sustained and complete improvement.  However, the evaluation must continue.  This graphic below demonstrates the steps in a successful QAPI program:

Need Assistance with QAPI?

In conclusion, a QAPI program is not just busy work that must be done because of the new CoP, but a true tool to enhance an agency’s outcomes, quality and operation. Your agency and your patients will benefit from a QAPI Program! The team at 5 Star Consultants has extensive experience with QAPI, including speaking on this key topic at conferences around the country. To learn how we can put our expertise to work for your agency,

please contact us at [email protected] or 866-428-4040.

Southern Web SupportQAPI – Are you Struggling to be Compliant with the new Conditions of Participation
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