F868
(Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24)
§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.
§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.
§483.80(c) Infection Preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.
DEFINITIONS
“Infection Preventionist (IP)”: Term used for the person(s) designated by the facility to be responsible for the infection prevention and control program. (Please refer to F882 for further information on the IP.)
“Non-physician practitioner (NPP)”: A nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA).
“Regular basis”: for the purpose of the infection preventionist reporting requirement, reporting should occur at the same frequency as the QAA committee meetings.
GUIDANCE
QAA Committee
QAA 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 monitor to ensure performance goals or targets are achieved, and revising 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, and/or department. The QAA Committee must be composed of, at a minimum:
• The director of nursing (DON),
• The Medical Director or his/her designee,
• The Infection Preventionist (IP), and
• At least three other staff, one of whom must be the facility’s administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems.
The facility may have a larger committee than required by the regulation. Residents and families may provide a valuable perspective to committee efforts, although their participation is not required. Representation by staff with responsibility for direct care and services provides perspectives that are valuable in identifying, analyzing and correcting problems in resident care areas. Additionally, departments such as maintenance, housekeeping, laundry services, and other service areas such as the business office should be provided opportunities to participate in the committee, when relevant performance data is discussed. Consideration should be given as to how committee information is provided to and from staff who may not be members of the committee, but whose responsibilities include oversight of departments or services.
As noted above, the Medical Director is a required member of the QAA committee. This requirement stems from the Medical Director’s responsibility for the overall medical care provided and the implementation of all resident care policies in the facility. There should be evidence of meaningful participation by the Medical Director in the QAPI program, such as reporting on trends identified during oversight and review of reports such as the report of irregularities from the medication regimen review, and other oversight activities. For additional guidance related to the Medical Director‘s role, see §483.70(g), Medical Director, F841.
The Medical Director’s designee must not be another required member, such as the DON, but may be an NPP. The designee must have knowledge of the facility’s policies, procedures and practices so that he/she can fully participate and can add value to the QAA committee comparable to the medical director. Having a designee for the QAA committee, does not change or absolve the Medical Director’s responsibility to fulfill his or her role as a member of the QAA committee, or his or her responsibility for overall
medical care in the facility. In addition, there must be evidence of communication of the content of the meeting to the Medical Director, with his/her acknowledgement of this information. The Medical Director, in conjunction with the QAA committee, may arrange for real-time alternative methods of participation, such as videoconferencing and teleconference calls. For additional guidance related to the Medical Director’s responsibilities, see §483.70(g) Medical Director, F841.
Infection Preventionist Participation on Quality Assessment and Assurance (QAA) Committee:
The IP must be a participant on the facility’s QAA committee and report on the IPCP and on incidents (e.g., healthcare-associated infections (HAIs)) identified under the program on a regular basis. Reporting may include, but is not limited to, facility process and outcome surveillance, outbreaks (ongoing and any since the last meeting) and control measures, occupational health communicable disease illnesses (e.g., TB, influenza) and the Antibiotic Stewardship Program (ASP) related to antibiotic use and resistance data. In order to be considered an active participant, the IP should attend each QAA meeting. If the IP cannot attend, another staff member should report on the IP’s behalf but this does not change or absolve the IP’s responsibility to fulfill the role of QAA committee member or reporting on the IPCP.
NOTE: Refer to §483.80(b), F882 for information on the infection preventionist's responsibilities and qualifications.
QAA Committee and the Governing Body
Functioning under the facility’s governing body, the QAA committee is responsible for reporting its’ activities, including the implementation of the QAPI program, to the governing body or designated person(s) functioning as the governing body.
Note: Small facilities might not have a Governing Body; there may only be an administrator who is already a required member of the QAA committee, and therefore, already apprised of QAPI activities.
Frequency of Meetings
QAA committee meetings must be held at least quarterly or more often as necessary to fulfill the committee’s responsibilities to identify and correct quality deficiencies effectively. The QAA committee determines what performance data will be monitored and the schedule or frequency for monitoring this data. There is no expectation that all performance data will be monitored at each committee meeting, however, the data must be reviewed with enough frequency to enable the committee to know if improvement is needed or if improvement is occurring (for current corrective actions).
INVESTIGATIVE PROCEDURE
Use the Facility Task Pathway for Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) Review, along with the above interpretive guidelines when determining if the facility meets the requirements for, or investigating concerns related to the QAA Committee.
Surveyors should refer to the following when investigating concerns and citing non-compliance related to QAPI:
• F865: For concerns related to whether a facility has implemented and maintains a comprehensive QAPI program and plan, disclosure of records and governance and leadership.
• F867: For concerns related to how the facility obtains feedback, collects data, monitors adverse events, identifies areas for improvement, prioritizes improvement activities, implements corrective and preventive actions, and conducts performance improvement projects.
• F868: For concerns related to the composition of the QAA committee, frequency of meetings and reporting to the governing body.
KEY ELEMENTS OF NONCOMPLIANCE
To cite deficient practice at F868, the surveyor's investigation must generally show that the facility failed to meet any one of the following:
• Establish and maintain a QAA committee;
• Ensure the QAA committee is composed of the required committee members;
• Ensure the QAA Committee reports its activities to the governing body; and/or
• Meet at least quarterly, and with enough frequency to conduct required QAPI activities.