The nurse assessment coordinator (NAC) brings a unique understanding of facility operations and resident needs that can reap critical benefits for the Quality Assurance and Performance Improvement (QAPI) program, says Lauren Stenson, MSN, RN, CNDLTC, QCP, DNS-CT, an AAPACN curriculum development specialist. “You keep track of the documentation that is occurring in the facility, you are the main driver behind the development of the comprehensive care plans, and you understand the care that is being delivered on the floor.”
So, the NAC is well-positioned to identify key trends that others may not see as easily, points out Stenson. “Going all-in on QAPI participation will help you ensure that residents receive the best care possible in alignment with the care plans that you create.”
The role of QAPI in survey—and beyond
Every nursing home is required by regulation to have an “effective, comprehensive, data-driven” QAPI program that “focuses on indicators of the outcomes of care and quality of life,” according to 42 Code of Federal Regulations (CFR) §483.75(a). The full QAPI regulations in §483.75, with an assist on QAPI training for staff in §483.95(d), are addressed in four F-tags in Appendix PP of the State Operations Manual, points out Stenson. These F-tags are as follows:
- F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt) addresses the nursing home’s need to implement and maintain a comprehensive QAPI program and plan, record disclosures, and governance and leadership.
- F867 (QAPI/Quality Assessment and Assurance (QAA) Improvement Activities) targets the requirements for obtaining feedback, collecting data, monitoring adverse events, identifying improvement needs, prioritizing improvement activities, implementing corrective and preventive actions, and conducting performance improvement projects (PIPs).
Note: Of the four QAPI-related F-tags, only F867 includes substantive revisions that will go into effect on April 28, 2025, according to the draft revised Appendix PP available in Quality, Safety, and Oversight (QSO) memo QSO-25-14-NH.
- F868 (QAA Committee) discusses who needs to be on the QAA committee, how frequent meetings must be, and the rules for reporting activities to the governing body.
- F944 (QAPI Training) addresses the components of the mandatory QAPI training program that the nursing home must provide to all staff.
F867 and the other QAPI F-tags remain fairly infrequent citations even though so far in fiscal year (FY) 2025, which runs Oct. 1, 2024 through Sept. 30, 2025, F867 is the 20th most common citation at the immediate jeopardy (IJ) level, according to QCOR data accessed April 11, 2025. “However, like a strong facility assessment, a well-run QAPI program that improves operational safety and quality is enmeshed in provider success in multiple care areas and F-tags,” notes Stenson.
“For example, the draft revised guidance for both F605 (Right to Be Free From Chemical Restraints/Unnecessary Psychotropic Medications) and F757 (Drug Regimen Is Free From Unnecessary Medications) discusses potentially monitoring the use of certain medication classes through QAPI,” explains Stenson. “In addition, the QAPI F-tags under §483.75 are potential tags for additional investigation in several citations, including F686 (Treatment/Services to Prevent/Heal Pressure Ulcers) and F692 (Nutrition/Hydration Status Maintenance).”
Further, QAPI is listed as an additional survey task to consider in multiple critical element pathways used by surveyors to investigate care concerns, adds Stenson. “For example, those include the Hospitalization Critical Element Pathway, the Accidents Critical Element Pathway, the Respiratory Care Critical Element Pathway, and the Unnecessary Medications, Chemical Restraints/Psychotropic Medications, and Medication Regimen Review Critical Element Pathway.”
What this all means is: QAPI is essential to proving optimal resident care, stresses Stenson. “Nurses in general want to do the best for residents, but in my experience, the NAC is especially invested. If you bring your unique insights to bear in QAPI, you can be a part of the solution for your residents.”
Steps that the NAC can take to participate more effectively in the QAPI program include the following:
Understand that MDS accuracy is central to QAPI success
CMS defines QAPI as follows under F865:
| “Quality Assurance and Performance Improvement (QAPI)” is the coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical and creative problem solving. |
“It’s impossible to achieve an effective data-driven approach without accurate data,” says Stenson. “You should educate all interdisciplinary team (IDT) members who participate in MDS coding on the coding instructions, including the look-back periods, in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual for the items that they code, and you should be in constant communication with those IDT members to meet the timelines for MDS completion and submission.”
Going on the floor and doing assessments—not relying totally on data that is available in the electronic medical record (EMR)—will help benefit the QAPI program in addition to improving the accuracy of MDS assessments, says Stenson. “Getting out and talking to staff members, residents, and families gives you an opportunity to multitask and obtain feedback to use in QAPI analysis while you are getting accurate assessment data to support MDS coding.”
The NAC also should conduct regular audits of MDS coding and supporting documentation, says Stenson. “You need to validate the MDS coding. For example, you could use some type of audit tool to identify errors and inconsistencies and then follow up to cross-check the supporting documentation in the medical record.”
Do some analysis as prep work
“Data is just information without good analysis,” says Stenson. “The NAC typically has strong analytical skills and access to a wide array of the data that the QAPI team has decided to monitor. You can help the rest of the QAPI team understand what the data means—and what the team may need to target in a PIP—with good preparation before the QAPI meeting.”
The NAC should review MDS assessments, care plans, and the MDS-based quality measures (QMs) from the Nursing Home Quality Initiative (NHQI), the Skilled Nursing Facility Quality Reporting Program (SNF QRP), and the Skilled Nursing Facility Value-Based Purchasing program (SNF VBP), suggests Stenson. “You also should consider other relevant data, including your observations on the floor and the documentation in the medical record that you have reviewed.”
The NAC can use all of that collected information to look for trends, areas for improvement, and quality gaps, says Stenson. “Then, you can bring forward more targeted information for review at QAPI meetings and make suggestions that will help the team identify tasks and prioritize effectively.”
Note: Learn about Internet Quality Improvement & Evaluation System (iQIES) reports that can assist with QAPI analysis in the chart at the end of this article.
Remember that all trends merit action
“You don’t want to ignore smaller problems that you identify just because they’re not PIP-level concerns,” says Stenson. “All issues and opportunities that you detect should be looked at in a QAPI meeting. The team then can address those easy issues right off the bat so that they don’t become a bigger, systemic issue.”
Stenson offers the example of the NAC assisting to update the Roster/Sample Matrix (form CMS-802) and noticing a slight upward trend of urinary tract infections (UTIs) in a small cluster of residents. “If you immediately bring this to QAPI, you can ensure that the infection preventionist (IP) is aware of it, and the QAPI team can work collaboratively with the IP to address that through, for example, providing a refresher on perineal care to staff on that unit. Targeting smaller issues will help prevent a larger incidence that could directly affect your QMs—and require a PIP.”
Actively participate in QAPI meetings
“QAPI must be an interdisciplinary process,” says Stenson. “The whole point of having a QAPI team is for everyone to actively participate. If you have done the prep work, you can provide valued input and ask important questions. You do the MDS assessments, you are on the floor with staff so you get to see staff in action, and you often dig deep into documentation and the medical record. You offer a very valuable perspective, and you can make a positive impact on your facility’s QAPI program if you commit to active participation.”
Assist with PIP development and monitoring
The NAC should work with other team members to develop effective PIPs or other corrective action plans for identified issues, says Stenson. “As the leader of care plan development, you are a pretty important player. You understand how to create measurable interventions to meet goals within specific time frames. You also serve as a role model for many nurses and other staff in your facility, so your buy-in as a nurse leader is crucial.”
The NAC also should contribute to PIP monitoring, says Stenson. “Once you have a PIP in place, the QAPI team needs to conduct continuous monitoring to ensure that the PIP is moving in the right direction. You can have eyes on the ground when you are out on the floor doing assessments, and you can also check on what’s happening during your documentation reviews.”
Go all in on education during a PIP
“Education is such an important part of QAPI,” says Stenson. “The QAPI team cannot expect to achieve sustained outcomes when making changes if staff and even residents don’t receive the education required to make those changes. All members of the QAPI team, including the NAC, should provide ongoing education during the rollout of a PIP.”
Also educate staff in real time before a PIP is required
Constantly reviewing documentation and doing assessments on the floor allows the NAC to quickly identify concerns before they become trends that merit a PIP, says Stenson. “You have a key role in education. You may be able to address some concerns promptly and directly with staff before they become a bigger issue. Or, you may need to coordinate with the director of nursing services or the staff education nurse so that they can act on your real-time information.”
Note: Want a refresher on QAPI basics to feel more confident participating? View the 60-minute Moving Forward Coalition presentation QAPI 101: What Is Quality Assurance [and] Performance Improvement? In addition, AAPACN maintains a QAPI and Quality Initiatives page with links to the latest information and resources about QAPI implementation. Finally, consider enrolling in AAPACN’s QAPI Certified Professional certification course to gain an even higher level of expertise.
iQIES Reports That Can Assist With QAPI Analysis
| Report Name | Report Category | Report Type | Report Purpose |
| MDS 3.0 QM Package | Package Reports | Quality Measure | Allows users to run one or multiple MDS 3.0 Quality Measure reports using the same report criteria selections for one or more providers in a single report request. All data for the selected reports will be returned in files separated by provider. |
| MDS 3.0 Facility Characteristics Report | Quality Measure | Facility-Level Quality Measure | Displays facility demographic information based upon data submitted in the MDS 3.0 records and includes comparison state and national percentages for a specified timeframe. By comparing the facility percentages with the state and national average percentages, you can determine whether the facility’s demographic characteristics differ from the norm. Facility characteristics may indicate a need to concentrate a review on certain resident groups. |
| MDS 3.0 Facility-Level QM Report | Quality Measure | Facility-Level Quality Measure | Displays the facility percentage and how the facility compares with other facilities in their state and in the nation for each quality measure. This report helps facilities identify possible areas for further emphasis in facility quality improvement activities or investigation during the survey process. |
| MDS 3.0 Resident-Level QM Report | Quality Measure | Resident/Patient-Level Quality Measure | Displays the residents (active and discharged) who were included in the calculations for the selected facility and period that were used to produce the MDS 3.0 Facility-Level Quality Measure (QM) Report. The report lists the residents by name and indicates the measures, if any, triggered by each. |
| SNF QRP Facility-Level QM Report | Quality Measure | Facility-Level Quality Measure | Provides facility-level quality measure results for a select 12-month period. Quality measure results are computed from the data submitted in the Minimum Data Set (MDS), Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN), and Medicare Fee-For-Service (FFS) Claims data sources. |
| SNF QRP Resident-Level QM Report | Quality Measure | Resident/Patient-Level Quality Measure | Lists each resident with a qualifying Minimum Data Set (MDS 3.0) record used to calculate the assessment-level quality measure values for a select 12-month period. The report displays each resident’s name and indicates how/if the resident’s stay affected the SNF’s quality measure scores. |
Note: Learn how to access SNF VBP reports here.
Source: Appendix A in the iQIES Report User Manual.
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