QAPI vs “Compliance and Ethics” Requirements
Jeannine LeCompte, Compliance Research Specialist
Understanding the different functions of the Quality Assurance and Performance Improvement (QAPI) program and the upcoming “Compliance and Ethics Program” will be important for long-term care (LTC) facility staff. Despite what appears to be confusingly similar semantics, the two programs deal with separate functions and duties, so a quick review is helpful.
QAPI was mandated by the Affordable Care Act of 2010. This required all nursing homes to have an “acceptable” QAPI plan in place, designed specifically to improve care while reducing per capita costs in the healthcare delivery system.
Historically, Quality Assessment and Assurance (QAA) committees have been charged with identifying any “quality deficiencies” and developing plans to correct them. Effective at the end of November 2017, CMS required all LTC facilities to have a QAPI plan ready for review by the state survey agency, with full implementation of the QAPI program by no later than November 28, 2019. The current QAA/QAPI Committee is a more effective effort that combines QAA and QAPI activities in order to improve their effectiveness at preventing rather than merely reacting to issues.
QAPI can be defined as the combination of two approaches to quality control management: Quality Assurance (QA) and Performance Improvement (PI). QA is the process whereby care at a facility is maintained at an “acceptable level” by ensuring that all facilities have minimum service thresholds.
QA also contains a reactive element to review deficiencies, correct them, and put processes in place to prevent such shortfalls occurring in the future. PI is a proactive study of systems and processes designed to preempt any problems through forward planning and the proactive testing of new solutions to ongoing or persistent problems.
The compliance and ethics program—due for implementation at the end of November 2019, requires “high-level personnel” who have “substantial control over the operating organization” to develop a compliance and ethics program which will be “effective in preventing and detecting criminal, civil, and administrative violations under the Act and in promoting quality of care.”
This will require the creating of a structure which will use written compliance and ethics standards, policies, and procedures designed to specifically prevent legal action—as opposed to Office of the Inspector General (OIG) punishments—from being inflicted on the organization.
This program must include anonymous reporting options, and an ability to review all programs, to ensure legal compliance. It should be noted it has been mandated that nursing facilities have a compliance and ethics committee and program in place as of the signing of the Affordable Care Act of 2010. While CMS will not cite facilities for failures of their compliance and ethics program related to the published F-Tags until November of 2019, the OIG is already enforcing requirements for a full program.
The distinction is clear: QAPI is primarily designed to ensure standards of care and service, and the compliance and ethics program is designed to ensure legal compliance.
