Daniel McElroy-TX

The Centers for Medicare and Medicaid Services is overlooking an opportunity to encourage quality assessment and performance improvement (QAPI) in Skilled Nursig Facilities (SNF) and Nursing Facilities (NF). No regulations, including §483.75(o), require SNF/NF QAPI and allow CMS to enforce QAPI in SNFs and NFs. No SNF/NF regulation sspecifically requires quality measurement. This is not consistent with the provisions of the Patient Protection and Affordable Care Act mandates quality assessment and performance improvement for all providers and suppliers. The July 12, 2010, Notice of Proposed Rulemaking issued regulations required by the Health Care Reform Act. This NPRM opened nursing home enforcement regulations for revision and improvement. However, CMS did not improve 42 CFR §488.400 and §488.402(a) which restrict the use of nursing home enforcement remedies, Especially Directed Inservice Training, Directed Plans of Correction and Civil Money Penalties. §488.400 and §488.402(a) state that, "the purpose of remedies is to ensure prompt compliance with program requirements." This narrow purpose gives CMS no authority to require a root cause analysis to identify deficient systems (typically failures in integrating and coordinating services and in communicating). These failures preclude developing, implementing, and measurably evaluating systems. That prohibits sustained compliance and continuous performance improvement. For 14 years (since 1995), CMS efforts to only “ensure prompt compliance" may have fostered "yo-yo compliance." It is time for CMS to enforce measured quality assessment and performance improvement in SNFs and NFs. A QAPI wording for might be §488.400 and §488.402(a): "The purpose of remedies is to ensure prompt and sustained compliance and continuous, measured performance improvement in care and services."