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June 12, 2014

Quality Assessment and Performance Improvement (QAPI) In Nursing Homes: Diverting CMS Attention from Enforcement

In the past few years, the Centers for Medicare & Medicaid Services (CMS) has focused considerable attention on Quality Assessment and Performance Improvement (QAPI) in nursing homes.  This focus, we fear, is diverting the agency's resources from enforcing the Nursing Home Reform Law.  

QAPI Under the Affordable Care Act

Section 6102(c) of the Affordable Care Act requires the Secretary of the Department of Health and Human Services (the Secretary) to "establish and implement a quality assurance and performance improvement [QAPI] program" for nursing facilities by December 31, 2011.[1]  Under this provision, the Secretary establishes standards for QAPI and provides technical assistance to facilities "on the development of best practices in order to meet such standards."[2]  Within a year of the promulgation of final regulations, facilities must submit a plan to the Secretary to implement QAPI. 

Although CMS has not yet promulgated regulations, it has contracted with the University of Minnesota and Stratis, the Minnesota Quality Improvement Organization (QIO), to develop QAPI.  In addition, CMS has issued four (4) Survey & Certification letters to state survey agencies.  The Survey & Certification letters describe:

  • The requirements of the law and plans to test a QAPI prototype in the summer 2011 (April 8, 2011),[3]
  • The development of QAPI tools and resources with the University of Minnesota and Stratis and distribution of Nursing Home Quality Improvement Questionnaire (sent to a representative sample of 4200 randomly selected nursing homes, to be evaluated by Abt Associates) (June 29, 2012), [4]
  • The Nursing Home QAPI Guide, QAPI at a Glance (Dec. 14, 2012),[5] and
  • The rollout of QAPI tools, newsletter, video, and website (June 7, 2013).[6]

Preliminary Concerns About QAPI

Many critical questions about QAPI remain unanswered in CMS's extensive materials.  For example, the fourth of five elements of QAPI is Performance Improvement Projects (PIPs), which CMS describes as:

a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements. The facility conducts PIPs to examine and improve care or services in areas that the facility identifies as needing attention. Areas that need attention will vary depending on the type of facility and the unique scope of services they provide.[7]

Questions include whether facilities will be specifically required to develop PIPs related to deficiencies that survey agencies cite and the number of PIPs a facility will be required to implement in order to be in compliance with QAPI.  (The latter concern is whether the completion of a single PIP on a relatively minor issue will be sufficient to demonstrate compliance with QAPI.)

Many advocates for nursing home residents view QAPI as a diversion from CMS's core function of enforcing federal law.[8]  Specific concerns are described below.


1.  QAPI is the latest in a long line of management tools that generally address the same principles and purpose.

Total quality management (TQM), continuous quality improvement (CQI), quality assurance (QA), quality assessment and assurance (QAAA), and now quality assessment and performance improvement (QAPI) are terms reflecting various approaches to quality of care management.  The goals of each of these management tools, as used in nursing facilities, are generally the same – to identify the causes of problems and to develop methods to fix them on a permanent or sustained basis. 

It seems unlikely that using the new term QAPI will lead to any different or better results for residents than the prior management tools because, like other such tools, QAPI does not mandate stability in nursing facility staffing or specific staffing levels or staff competencies.   For advocates, adequate and appropriate staffing is the key to improved quality of care and quality of life for residents.  A new management practice tool will not increase staffing or improve the quality of care or the quality of life for residents.

2. The survey process should focus on the outcomes for residents, not internal management practices that facilities use to identify and correct problems. 

The survey process is intended to identify noncompliance with federal Requirements of Participation.[9]  It is facilities' responsibility to identify the causes of the problems and to fix them.  Whatever management tools facilities use to identify and correct problems is not the critical issue for the survey agency; the results for residents are.

3. The plan of correction process already requires that facilities identify and correct care problems for residents who are specifically identified in a deficiency, assure that other residents are not harmed, and take sufficient actions to ensure that deficient practices do not occur again. 

In the federal survey and enforcement system, facilities that are cited with a deficiency are required to develop a plan of correction (PoC).[10]   As described by the State Operations Manual, which is CMS's official guidance to surveyors, "an acceptable plan of correction" must:

  • Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;
  • Address how the facility will identify other residents having the potential to be affected by the same deficient practice;
  • Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;
  • Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and
  • Include dates when corrective action will be completed…[11]

If a PoC does not include all of these elements, it is rejected[12] and the facility is terminated from participation in the Medicare and Medicaid programs.[13]  In short, the PoC process already requires facilities to identify and correct all problems that are cited as deficiencies.  QAPI is duplicative, redundant, and far more limited in scope.

4. Facilities are unlikely to be able to implement QAPI, as described by the extraordinarily time- and staff-intensive process that CMS identified in the guidance. 

The 41-page document about QAPI, distributed by CMS in 2012, QAPI at a Glance: A Step by Step Guide to Implementing Quality Assessment and Performance Improvement (QAPI) in Your Nursing Home, [14] includes 12 steps that facilities, as they currently operate, have neither the time nor the staff to implement.  Step 1 alone, for example, called "Leadership Responsibility and Accountability," calls for facilities to develop a Steering Committee for QAPI, suggests that QAPI team meetings occur during work hours (and that additional staff fill in while team members are at meetings), and suggests that team members may be sent to specialized trainings.  Facilities do not employ extra staff, as contemplated by QAPI.

5.  CMS appears to be poised to reduce survey and certification activities in facilities that have QAPI.

The most serious concern is that QAPI may be used as an excuse to reduce public oversight of quality of care in nursing facilities.  The CMS budget justification for Fiscal Year 2015 suggests the possibility of conducting less than full surveys in organ transplant centers that use QAPI.  CMS writes, "a targeted survey that focuses on an organ transplant center's quality assessment and performance improvement system may provide an efficient method of gaining insight into the overall center performance and reduce the need for more frequent, full surveys [emphasis supplied]."[15] 

Through the 9-15 month survey cycle, the federal Medicare and Medicaid statutes require annual surveys in nursing homes and require regulatory agencies to give more intensive and frequent scrutiny to facilities with quality problems.[16]   The budget document quoted above, however, suggests that CMS may view QAPI, by itself, as a justification for less intensive surveys.  Advocates' concern is that CMS may apply this rationale to nursing facilities sometime in the future. 

The connection between QAPI and reduced survey frequency and intensity is very troubling.  Providers' internal quality assurance programs, by whatever name, should not be relevant to the performance of regulatory agencies' oversight function.

The nursing home industry often proposes and supports policy and regulatory changes that would decimate the survey process and the enforcement system.[17]  Given this history[18] and ongoing industry efforts,[19] advocates are concerned that facilities will use QAPI as a tool to weaken, rather than enhance, quality standards and enforcement efforts. 

Finally, advocates fear that private companies offering "accreditation for QAPI"[20]  will replace the federal oversight and enforcement function.  It does not take much of a stretch to see legislative proposals to reduce public surveys in nursing facilities whose QAPI is privately accredited.  Advocates fear a return to 1982, when the Administration proposed less-than-annual surveys for nursing facilities, self-surveys, and deemed status for facilities accredited by what was then called the Joint Commission on the Accreditation of Hospitals.[21]  Those proposed regulations led to two Congressional moratoria preventing deregulation of nursing homes, the Institute of Medicine report Improving the Quality of Care in Nursing Homes (1986), and the Nursing Home Reform Law (1987). 


Survey agencies should focus on the core functions that no other public or private entity has authority to perform – enforcing the law that governs the provision of nursing facility care to residents.  If nursing facilities do not know how to provide care to their residents, they have resources to hire consultants to help them.  It is not the role of government to pay billions of dollars for nursing facility care annually and also teach facilities how to manage themselves in order to provide the care that they have contracted, and are paid, to provide.

[1] 42 U.S.C. §1128I(c).
[2] Id.
[3] CMS, "Quality Assurance and Performance Improvement (QAPI) Initiatives related to Section 6102(c) of the Affordable Care Act for Nursing Homes," S&C: 11-22-NH (April 8, 2011),
[4]  CMS, "Quality Assurance and Performance Improvement (QAPI) in Nursing Homes – Activities Related to QAPI Implementation," S&C:12-38-NH (June 29, 2012),
[5]  CMS, "Preview of Nursing Home Quality Assurance & Performance Improvement (QAPI) Guide – QAPI at a Glance," SUC: 13-05-NH (Dec. 14, 2012),
[6]  CMS, "Rollout of Quality Assurance and Performance Improvement (QAPI) Materials for Nursing Homes," S&C: 13-37-NH (June 7, 2013), .
[8] The Nursing Home Reform Law provides, "It is the duty and responsibility of the Secretary to assure that requirements which govern the provision of care in skilled nursing facilities under this subchapter, and the enforcement of such requirements, are adequate to protect the health, safety, welfare, and rights of residents and to promote the effective and efficient use of public moneys."  42 U.S.C. §§1395i-3(f)(1), 1396r(f)(1), Medicare and Medicaid, respectively.
[9] 42 U.S.C. §§1395i-3(g), 1396r(g); 42 C.F.R. §§488.300-.335.
[10] 42 C.F.R. §488.402(d).
[11] Chapter 7, §7304.4,  Scroll down to pp. 51-52.
[12] Id. 52.
[13] 42 C.F.R. §488.456(b)(ii).
[15] Department of Health and Human Services, Fiscal Year 2015, Centers for Medicare & Medicaid Services, Justification of Estimates for Appropriations Committees,, page 18.
[16] 42 U.S.C. §§1395i-3(g)(2)(A)(iii) (survey frequency), 1395i-3(g)(2)(B) (extended surveys), 1395i-3(g)(3) (validation surveys), 1396r(g)(2)(A)(iii) (survey frequency), 1396r(g)(2)(B) (extended surveys), 1396r(g)(3) (validation surveys).
[17] See "Federal Nursing Home Enforcement System Is Not Punitive: Setting the Record Straight Again" (Weekly Alert, May 8, 2014 ),
[18]   CMA, "Back to the Future: Nursing Home Industry Makes Secret Survey and Enforcement Proposals to Congress" (Weekly Alert, April 16, 2009),
[19] See LeadingAge, Broken and Beyond Repair: Recommendations to Reform The Survey and Certification System,[1][1].pdf; Leading Age, Strategic Plan 2014-2018,; and Leading Age, Policy Statement, March 11, 2014), Barbara Gay, "2014 Quality in Nursing Home Care" (Policy Statement, March 11, 2014),
[21] 47 Fed. Reg. 23,403 (May 27, 1982).  


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