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White Papers

Developing an Effective Quality Assurance Program (2012)
Read about the government's new requirements for Quality Assurance and Performance Improvement (QAPI) and mandatory corporate compliance programs as outlined in the 2010 Affordable Care Act.

Click here for an abstract of this white paper.
The Case for Compliance (2011)
Read about the Office of the Inspector General's mandatory compliance guidelines including exclusions checks, education and training, and how to achieve compliance throughout a facility.

Click here for an abstract for this white paper.

For the full text of these white papers, please click here.

White Paper Abstracts

Developing an Effective Quality Assurance Program: Turning minimum requirements into a comprehensive strategy (2012)

With the Omnibus Budget Reconciliation Act (OBRA) of 1987, the U.S. government took a first and significant step toward enforcing quality of care in nursing homes. Twenty years later, a report by the Kaiser Family Foundation cited that as many as 90% of all SNFs were still being cited for one or more deficiencies in 2006, including nearly one-fifth of them for harm or immediate jeopardy caused to residents.

The Affordable Care Act (ACA) of 2010 was the government's response. With this new legislation, each nursing home must institute a compliance program by the end of 2013 and a quality assurance and performance improvement (QAPI) program soon after.

Taking a step beyond OBRA '87, the Centers for Medicare and Medicaid's new QAPI regulations will introduce performance improvement as a key ingredient while CMS is required by the ACA to "provide technical assistance to facilities on the development of best practices" in attaining QAPI. In July 2011, CMS released the "5 Elements of QAPI," the first significant program documentation, to be used by nursing homes as an initial framework for their individual QAPI programs.

"Performance improvement (PI) is the new kid on the block; nursing homes are already required to have quality assurance. PI is a proactive effort to use data to understand and improve your own problems. It includes formal Performance Improvement Projects, root cause analysis and above all, systems thinking," said Dr. Rosalie Kane, Professor, Division of Health Policy & Management, University of Minnesota and CMS' QAPI demonstration project director. "Performance improvement is really an internally-driven effort by programs and services to improve what they do overall and to gradually bring up performance across the board. It's a striving for excellence."

QAPI programs will seek to create a facility and corporate-wide infrastructure that supports and effectively strengthens a nursing home's internal capacities for data collection and analysis, while developing strategies that can identify the causes of both persistent and isolated problems and develop plans to prevent them.

"There is substantial development and testing of a variety of materials... in other environments in various nursing homes and through some of the professional organizations, QIOs and other entities as well," said Alice Bonner, PhD, RN, Director, Division of Nursing Homes, Survey and Certification Group, CMS. "We're working closely with numerous partners to be sure that information that will be able to help nursing homes, such as technical assistance, is as widely available as possible as we move toward national rollout." (Back)

The Case for Compliance: Quality of care takes center stage for today's nursing homes (2011)

Government investigations of America's 17,000 skilled nursing facilities are on the rise. Between 2005 and 2007, more than 91% of nursing homes were cited for deficiencies during annual surveys, with increasing quality of care deficiencies, according to a 2008 report by the Office of the Inspector General of the Department of Health & Human Services.

Since the first Corporate Integrity Agreement (CIA) focusing on quality of care went into effect in June 2000, more than 35 nursing home corporations have entered into such agreements, according to an April 2009 OIG report. Moving beyond solely targeting large corporations in the last decade, the U.S. government has come to expect accountability from all size nursing home corporations. In fact, all of the CIAs currently in place are with single facilities or small, corporate chains operating between two and 40 nursing homes.

As a result of the deficiencies they are seeing in SNFs regardless of size, the U.S. government created its own "insurance policy" called compliance.

With the passage of HR 3590: the Patient Protection and Affordable Care Act of 2010, the U.S. Congress mandated nursing home compliance.3 By March 23, 2013, all SNFs must have a compliance program in operation that meets the new legislation's criteria. While the specifics of HR 3590 have yet to be spelled out, the OIG Compliance Program Guidelines (CPG) for Nursing Facilities are likely to provide the framework for compliance requirements.

Making quality assurance the focal point of compliance programs, HR 3590 will usher in a new era of quality of care and accountability for providers and their residents.

"In this day and age, for an entity not to have a compliance program in place is foolish," said legal regulatory and clinical compliance attorney David Hoffman, President, David Hoffman & Associates, PC, Philadelphia ( "Effective compliance is good for the organization; it protects the owners, their facility, its staff and the residents. It's all about protection and not being placed in a position where you're on the defensive. That's the worst position to be in."

As the penalties and liabilities for insufficient oversight rise and the 2013 compliance deadline approaches, SNFs will begin incorporate compliance into their day-to-day operations. (Back)