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F944
(Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22)
§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.
DEFINITIONS
“Quality Assurance and Performance Improvement (QAPI)” is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving
safety and quality in nursing homes while involving residents and families in practical and creative problem solving (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapidefinition, accessed 12/18/2020).
GUIDANCE
For the purpose of this guidance, the term “staff” includes all new and existing facility staff (with direct and indirect care functions); individuals providing services under a contractual arrangement; and volunteers, consistent with the volunteers’ expected roles (see requirements in §483.95).
Facilities must conduct mandatory training, for all staff, on the facility’s QAPI Program, that includes the goals and various elements of the program. It should also include how the facility intends to implement the program. The training should also include the staff’s role in the facility’s QAPI program and how to communicate concerns, problems or opportunities for improvement to the facility’s QAA Committee.
As updates are made to the facility's QAPI program or goals, the facility's training should also be updated and staff trained on the updates, as appropriate.
All training should support current scope and standards of practice through curricula which detail learning objectives, performance standards, and evaluation criteria. There should be a process in place to track staff participation in the required trainings.
PROBES
• Verify that the facility has a mandatory requirement that all staff receive QAPI training.
• Does the facility have a method for verifying staff attendance at the mandatory QAPI training? If so, do these records confirm that staff attended the mandatory QAPI training?
• Does the facility’s training program inform staff of the current elements and goals of the facility’s QAPI program?
• Are staff aware of what the facility’s QAPI program entails and how the facility intends to implement and monitor their program?
• Are staff aware of how to bring ideas or concerns to the attention of the QAA committee?
• How does the facility determine when training content requires updating to be consistent with current professional standards and guidelines?
It is not required to have an outcome deficiency cited for this tag to be cited for deficient staff training. If QAPI deficiencies are identified, refer to §483.75 for citation authority.
POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION
• F865-F868: for concerns related to the facility’s QAPI program.

 

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