Are you prepared for QAPI?

May 29, 2018

CMS has provided a basic framework for a Performance Improvement program with the new Conditions of Participation (CoPs) rule. Scheduled for phase-in on January 13, 2018 initially, QAPI compliance requirement was moved to July 13, 2018. As of this time, July 13, 2018 is the final deadline for agencies to get going on their QAPI program.

What is QAPI?

QAPI is an acronym for Quality Assessment and Performance Improvement. According to §484.65 of the new Conditions of Participation, agencies will be responsible for all aspects of their QAPI program and have a fair amount of freedom in how they choose to “develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program”. However, there are some guidelines that all agencies must follow.

What should I do first?

Any personnel who are directly involved with your agency’s QAPI program must read through §484.65 of the new Conditions of Participation. Going forward, it should be included in the orientation materials for all new employees, especially those who will be involved with QAPI. Provide a copy to your Governing Body to review and ensure that they accept their new role to judge the appropriateness of the scope of the program and collaborate with Quality Improvement personnel.


Your QAPI program must represent your whole agency and the services it provides. This means that if you have branches or subparts or if you utilize contract services, all of those aspects must be considered in your QAPI program. Start to develop processes to distribute and track information and education to direct hire employees and contract employees. Talk to contract company management to find a way to demonstrate the cooperation of their employees.


Review your CASPER, CAHPS, Home Health Compare, and PEPPERreports as well as infection control and incident reports to identify problem areas for your agency. Over the next few weeks, we will be releasing articles about these reports to help you access them and interpret what they mean.

If you didn’t document it, you didn’t do it

Surveyors will want to see your documentation to demonstrate your compliance with QAPI. Make sure you have your analysis, actions and conclusions put together in a place where they can be easily accessed. Develop tracking systems to keep organized. Review incident and infection reporting forms to ensure that they capture all of the information you will need in your analysis or revise them if needed. Keep minutes of meetings of the QAPI committee and the Governing Board.

The Wrap-Up

It can be hard for agencies to allocate resources to a program that is not directly tied to patient care. However, it is important to ensure you develop a thoughtful and appropriate QAPI program for your agency. A good program can improve patient care and outcomes, increase profit margins, and boost employee morale and efficiency. Not to mention, it’s the law and non-compliance puts your agency at great risk of monetary penalties and loss of certification.

therapyBOSS can help

Use our messaging system to easily communicate with all the members of the care team and coordinate education. Use service compliance tools to ensure clinicians are visiting patients timely and within frequency. Use scheduling to coordinate care and monitor activity. And keep checking our blogs for new and updated information and features.