AHCA Quality Summit Outcome

Nancy Leveille in Clinical & Quality

Nancy Leveille attended AHCA/NCAL’s Quality Summit last week in New Orleans. Two important aspects from the conference are summarized below. 

1.  Karen Tritz, CMS Director of the Division of Nursing Homes, Survey & Certification Group at CMS, was the closing keynote speaker. She addressed the following issue related to the new survey process.

  • Nationally, the surveys are taking longer due to the learning curve of both surveyors and providers.
  • The top issues they are currently identifying are in the elements of infection control, accidents and supervision and food preparation.
  • The new CMS guidance has included holding both the provider and individual responsible for accidents with injury even where the facility had all procedural steps to prevent the accident in place and the individual independently did not follow the plan of care. There was a lot of discussion from providers on this topic. Providers argued what would be the remedial plan of care if all items had been established by the facility to prevent occurrence. Ms. Tritz is going to reassess the issue.
  • During the open discussion the number of IJ’s being cited, especially in particular regions of the country, along with the stacking of additional F-tags increasing the total number of IJ’s was highlighted. Ms. Tritz emphasized there should be no stacking of deficiencies in the new survey process. Each deficiency must be able to stand on its own. AHCA will continue the dialogue with CMS on these issues. AHCA’s survey, regulatory and clinical committees are providing input from each state. Lisa Volk is on the Clinical Committee. 

The critical elements on the CMS.gov website and the educational materials for surveyors and providers are good resources to help prepare for survey.

2.  AHCA/NCAL announced its new program Quality Initiative and its four measures. This is a 2018-2020 initiative to continue to pursue reduction of high risk high volume quality issues across the country. 

The four Quality Measures are:

  • Hospitalizations – Safely reduce long-stay and short-stay hospitalizations by improving 10% (Q1 2017 baseline rates)-or maintain a rate of 10% or less-by March 2021.
  • Customer Satisfaction – Improve long-stay and short-stay satisfaction by 10% (Q1 2017 baseline rates)-or achieve a rate of >90%-by March 2021.
  • Functional Outcomes – Improve functional outcomes (self-care ad mobility) by 15% (Q1 2017 baseline rates) by March 2021.
  • Antipsychotic – Safely reduce the off-label use of antipsychotics by 10% (Q1 2017 baseline rates)-or maintain a rate of 8% or less in long-stay residents, and maintain a rate of 1% or less in short-stay residents-by March 2021. 

These four goals line up with the core issues in the national value based purchasing and NYS Nursing Home Quality Initiative (NHQI). For full information and resources to pursue the AHCA Quality Initiative, go to www.ahca.org and click on the Quality Initiative.


Nancy Leveille, RN, MS
Executive Director
518-462-4800 x20