QAPI and Facility Administration Flashcards

How often must a nursing facility's Quality Assessment and Assurance (QAA) committee meet at a minimum?

Answer: Quarterly

Section 483.75(g)(2)(i) requires the QAA committee to meet at least quarterly to coordinate and evaluate QAPI activities.

Which person is a REQUIRED member of the QAA committee under 42 CFR 483.75(g)?

Answer: The director of nursing services

The QAA committee must include the director of nursing services, the medical director or designee, the infection preventionist, and at least three other staff, one of whom is the administrator, owner, board member, or another leadership individual.

Regarding QAA committee records, surveyors generally:

Answer: May not require disclosure of QAA records except to determine compliance with the QAA requirements themselves

Under 483.75(h)-(i), the State or Secretary may not require disclosure of QAA records except to determine compliance with the QAA requirements. Good-faith attempts by the committee to identify and correct quality deficiencies may not be used as a basis for sanctions.

At a minimum, how often must a facility review and update its facility assessment, which determines the resources needed to care for its residents?

Answer: Annually, and whenever a change requires an update

The facility assessment (now 42 CFR 483.71) must be reviewed and updated as necessary, and at least annually. It covers the resident population, staff competencies, and resources.

Under the compliance and ethics program requirement (42 CFR 483.85), operating organizations with how many or more facilities must have additional elements such as a designated compliance officer?

Answer: 5

Organizations operating five or more facilities must meet additional requirements. These include mandatory annual training, a designated compliance officer reporting to the governing body, and compliance liaisons at each facility.

Under 42 CFR 483.70, which responsibility belongs to the facility's medical director?

Answer: Implementing resident care policies and coordinating medical care in the facility

The medical director is responsible for implementing resident care policies and coordinating medical care in the facility. Residents keep the right to choose their own attending physician.