CoP Educational Series Part 10: QAPI and Infection Prevention and Control

Posted on Thursday, July 13, 2017 8:28 PM

The final post in the Home Health Conditions of Participation series will cover the new CoPs – 484.65 Quality Assessment and Performance Improvement (QAPI) and 484.70 Infection Prevention and Control.

The Quality Assessment and Performance Improvement or QAPI requires home health agencies to develop, implement, evaluate and maintain an effective ongoing, agency wide, data driven program. The agency’s governing body must ensure the program reflects the complexity of the organization and services; (including those provided under contract or arrangement); focuses on indicators that relate to positive outcomes, including hospital admissions and re-admissions. The program must also take actions that address the agency’s performance across the spectrum of care, including the prevention and reduction of medical errors. Documented evidence of the QAPI program must be kept by the home health agency, as well as the ability to demonstrate the programs operation to CMS.

The first standard for this new CoP is: 

A. Program Scope
1. The program must at least be capable of demonstrating measurable improvement in indicators for which there is evidence that there is improvement in indicators that improve health outcomes, patient safety and quality of care.
2. The agency must measure, analyze and track quality indicators, including adverse patient events and other aspects of performance that enable the home health agency to assess processes of care, agency services and operations.

The second standard is:

B.Program Data – the home health agency QAPI program must use quality indicator data, including measures derived from OASIS, where applicable, and other relevant data in the design of it’s program. The agency must also use the data collected to monitor the effectiveness and safety of services and quality of care, as well as identify opportunities for improvement. Lastly the frequency and detail of the data collection must be approved by the home health agency governing body.

Program Activities is the third standard in this new CoP.

The home health agency performance improvement activities must focus on high risk, high volume or problem-prone areas.  The agency must consider incidence, prevalence and the severity of the identified problems in those areas and lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. The performance improvement activities must track adverse patient events, analyze their causes and implement preventative actions.

The home health agency must take actions aimed at performance improvement, and after implementing those actions, the agency must measure its successes and track performance to ensure the implemented improvements are sustained.

The timeline of home health agencies to begin conducting performance improvement projects is January 13, 2018 as detailed in the fourth standard of the CoP.

The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity and past performance of the agency’s services and operations. The agency must document the quality improvement projects undertaken, the reasons for conducting the identified projects and the measurable progress achieved on each one. A phase in was added that allows home health agencies the time necessary to collect the data prior to implementing the performance improvement projects. This allows for a full 12-month time-period between the time the final rule was published and the time agencies must begin conducting performance improvement projects.

This CoP also has language that outlines executive responsibilities. The governing body is responsible for ensuring that the ongoing program for quality improvement and safety is defined, implemented and maintained. They are also responsible to ensure the home health agency-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated for effectiveness. The governing body must make certain there are clear expectations for patient safety and they are established, implemented and maintained. If any evidence of fraud and abuse or waste is detected, they are appropriately addressed.

The second new CoP that is being covered – 484.70 Infection Prevention and Control requires a home health agency maintains and documents an infection prevention and control program which has a primary goal of preventing infection and communicable diseases.  Many agencies already have rigorous infection control and prevention programs in place, but with the revised CoP, this is a requirement for all home health agencies.

The standard for Prevention states the home health agency must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. The standard for Control requires the home health agency must maintain a coordinated agency-wide program for surveillance, identification, prevention, control and investigation of infectious and communicable diseases that is an integral part of the home health agency’s QAPI program. The infection program must include a method for identifying infectious and communicable disease problems and a plan for appropriate actions that are expected to result in improvement and disease prevention.

The home health agency is also required to provide infection control education to all staff, patients and caregivers. Documentation and tracking of completed education must be maintained.

This concludes the final post of the Home Health Conditions of Participation series.  The next 6 months are a crucial time period for agencies to begin preparing for these new requirements.

Written by Peggy Patton, Vice President of Education Services

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