Regulatory Compliance

With its focus on engagement, person-centered care, and overall quality of life for residents, the EPASS is a great tool to assist facilities in being CMS F-tag and QAPI compliant.

F-Tag Compliance in Skilled Nursing Facilities

The below table describes how using the EPASS in your facility may increase your compliance with the Centers for Medicare & Medicaid (CMS) F-tags for quality of life. Download a printable handout with this information: ftag-compliance-handout2018.

New Regulatory Compliance Chart 2018

F-tag information obtained from CMS

QAPI Initiatives

QAPI is the merger of two complementary approaches to quality, Quality Assurance (QA) and Performance Improvement (PI).  Both involve seeking and using information, but they differ in key ways:

QA is a process of meeting quality standards and assuring that care reaches an acceptable level.  Nursing homes typically set QA thresholds to comply with regulations.  They may also create standards that go beyond regulations.  QA is a reactive, retrospective effort to examine why a facility failed to meet certain standards.  QA activities do improve quality, but efforts frequently end once the standard is met.

PI (also called Quality Improvement – QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems.  PI in nursing homes aims to improve processes involved in health care delivery and resident quality of life.  PI can make good quality even better.

QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes.  The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions.

Centers for Medicare & Medicaid Services (CMS)

Skilled nursing facilities are required to have a QAPI procedure in place, and have on-going initiatives to uphold QAPI standards. Utilization of the EPASS, and generating engagement reports may be included in your facility’s QAPI procedure. Click HERE to learn more about generating reports.