Nursing Home and Hospitals are responsible for ensuring their systems are correct and are working. This involves quality improvement activities. Nursing homes and hospitals have federal and state regulations that address quality assessment and assurance.  The nursing home and hospital surveyors will use these regulations and the guidance at the regulations to determine if a nursing home or hospital is indeed in compliance with the regulations.

In nursing homes these regulations are located at CFR 483.75(o), which is F-tag 520.

The nursing home regulation states:
(1) A facility must maintain a quality assessment and assurance committee consisting of –
(i) The director of nursing services;
(ii) A physician designated by the facility; and
(iii) At least 3 other members of the facility’s staff.
(2) The quality assessment and assurance committee –
(i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and
(ii) Develops and implements appropriate plans of action to correct identified quality deficiencies.
(3) State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section.
(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

What this says, in a nutshell, is that the facility is responsible for finding out what its problem areas are and then is responsible for fixing them.

When a surveyor goes into a nursing home they will be looking to see that the nursing home has a quality assessment and assurance committee that includes the director of nursing, a physician, and at least three other staff. The physician on the committee does not have to be the Medical Director of the facility. The other staff, in a really good facility, will include staff who have the authority to change systems that need changing. This would include the administrator or the assistant administrator. It would also include the medical director, since part of his/her responsibilities includes guiding the facility in developing, implementing, and coordinating resident care & medical care. Other staff who should be involved in a good Quality Assessment and Assurance committee includes “front line” staff who do actual care for the residents. A nurse’s aide or two can provide valuable insight to help the committee determine where its weaknesses are. Therapy representatives, dietary staff, activity personnel, maintenance, housekeeping, and laundry staff would all be a part of an effective quality committee.

The nursing home and hospital surveyor will also look to see that the committee meets at least 4 times a year. In reality a good committee would me more frequently than that, usually once a month, but the requirement is only 4 times a year.

The committee needs to identify the problems in the facility and develop and implement policies and procedures to correct these problems. The committee also needs to monitor the things they implement to ensure they do correct the problem and that they continue to keep the problem corrected.

The committee looks at the entire facility, not just nursing areas, it looks at all levels of the facility staff, meaning the lowest person to the highest manager. It especially looks at all the issues that affect residents, meaning all issues, since all issues affect residents in one way or another. It looks at contracted services as well as services provided in house. The reason a good quality assessment and assurance committee looks at all these areas is to continually evaluate facility systems with in order to keep systems functioning satisfactorily and consistently. The committee is charged with preventing problems with care processes in the facility, and for correcting care processes that are not correct.

The QAA committee should be keeping minutes and documents to show the problems it identifies and the fixes it put into place to correct the problems, as well as documentation on the ongoing monitoring and surveillance that is performed throughout the facility. It is this ongoing monitoring and surveillance that will help the committee determine where the problems are and if the fixes are working. The committee’s minutes should include a thorough analysis of the problem(s) as well as action plans designed to correct the problem.

When a nursing home and hospital surveyor goes into the nursing home, he/she may not review the minutes of the committee, unless the committee chooses to provide them. It is usually suggested even if the facility provides them, that the surveyors not look at them. It is better for the surveyors to fid the problems through good methods of investigation than to rely on what the facility found. Not reviewing the facility minutes will help the survey agency if the facility decides to “fight” the deficiencies. They can’t say that the surveyors found the problems by looking at the facility’s own quality improvement activities.

What the nursing home and hospital surveyor does need to do, though, is look at the process the committee has in place and the types of documents they use to collect data.  When a facility has repeated, systemic problems, the quality regulation at F 520 is also usually in non compliance too. This is basically because a well functioning quality assessment and assurance committee should have found the problem and corrected it before the state survey agency did.

We will discuss Hospitals in the next post.


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