CMS Issues Updated Medication Pass Protocol and QAPI Materials

Nancy Leveille and Karen Morris in Clinical & Quality

On Friday, June 7, 2013, CMS released  1) changes to the SNF/NF Survey Medication Pass Protocol (including a form for use by surveyors); and 2) introductory materials for providers to use related to the Quality Assurance and Performance Improvement [QAPI] program.  The implementation date for the survey protocol changes is July 1, 2013.

At this time, the links on the CMS website are not live so I’ve attached the materials for your reference. 

According to CMS, the Medication Pass protocol has been modified to more effectively utilize surveyor resources and on-site survey time. For the Traditional Survey this protocol revision eliminates the requirement to extend the medication pass for another 20-25 opportunities if errors are detected in the first 20-25 observations.  Additional guidance specifies that the surveyor will watch and document all of the resident’s medications being administered at the time of the observation. Surveyors will not stop the observation in the middle of a resident’s medication pass.  If the surveyor reaches 25 medication observation opportunities when there are medications remaining for that resident, observe all medications being administered and add those opportunities to the total medication administration sample.

AHCA is very pleased that the QAPI resources will now be easily available to providers.  CMS is making the following set of introductory materials available on the CMS QAPI website:

  • QAPI at a Glance – a guide for understanding and implementing QAPI in nursing homes
  • QAPI Tools – process tools, within QAPI at a Glance, to help providers establish a foundation in QAPI
  • QAPI News Brief – newsletter describing basic principles of QAPI
  • Video – Nursing Home QAPI – What’s in it for you? -  introduces QAPI, its value to residents, their families and caregivers, and what is in it for nursing homes that embrace QAPI

Also, a new webpage to house QAPI training materials, tools and resources has been created on the CMS website.  Moving forward, CMs plans to expand its QAPI efforts by developing resources for consumers.

We anticipate that all materials and links will be live on the CMS website sometime today.

Lyn Bentley, MSW
Sr.Director of Regulatory Services
1201 L St., NW
Washington, DC 20005



Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20
  Karen Morris, RN, MS
Director, Clinical & Quality Services
518-462-4800 x15

Refer to #2013-309