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Condition of Participation Part 3

Quality Assessment Performance Improvement

Here’s some good news.  This provision replaces the former conditions at §484.16, “Group of professional personnel,” and §484.52, “Evaluation of an agency’s program.”  Those annual meeting minutes are now going to look suspiciously like QA reports.  I will miss being a community representative at all those dinners and want to point out that there is nothing in the CoP’s prohibiting agencies from taking their favorite consultant to dinner.

Agencies are free to design their own QA plans and formats as long as they include the following elements plus the infection control component below.

  1. Use of objective measures to demonstrate improved performance (Julianne’s note: Whenever possible, use data that is already being collected like OASIS or HHCAPS)
  2. Tracking performance to ensure that improvements are sustained over time
  3. Setting priorities considering prevalence, severity of identified problems; giving priority to activities affecting clinical outcomes
  4. Reflect the scope, complexity and past performance of the agency and documentation of projects.

Many agencies are already doing this and many are not.  Agencies that are accredited by the JCAHO, CHAP and ACHC and adhere to their standards are probably compliant but there are also agencies who choose to focus on dumb stuff that never actually happens to avoid looking bad.  Surveyors are not generally impressed when you show that 100 percent of your nurses now wear agency approved socks to match scrubs in the home environment.  The point is to make the focus of your work matter to your patients.

To determine what matters to your patients, have a meeting with all the visiting staff.  Where are the cracks and what is falling through them?  Examine all hospitalizations in the past quarter.  Ask patients and their caregivers.

Quality Assurance is not only about reading notes as they come into the agency.  It does not require an advanced degree and elaborate diagrams, either.  Somewhere in between these two extremes lies the sweet spot for an effective QA plan.  As you design or re-design your plan and implement it, avoid comparing it to someone else’s.  The only criteria are that it contains these elements and that it works to measure the improvements your agency make’s in patient care.


  • Determine if your agency’s plan incorporates all four requirements
  • Have meeting with a simple agenda so leadership knows what activities are currently being undertaken and determine how to expand upon them so that your plan meets these guidelines.
  • Use OASIS data or other assessment elements if appropriate to avoid additional data collection.
  • Chose projects that focus on patient care.
  • Call computer vendor to determine what reports may be used.
  • Learn to make pretty charts in Excel or Word and then post them for your staff to see.


Infection prevention and control

I was surprised to find that Infection control was a new addition to the Conditions of Participation.  There are state standards and OSHA standards that apply to home health.  The CDC does not have authority to ‘mandate’ actions but OASIS typically defers to the CDC’s extensive research to determine their course of actions.  But the conditions of participation have been silent all these years.  So, just in case you were not doing it right for other regulatory bodies, here’s some instructions on how to do right within the confines of the CoP’s.

The agency must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s QAPI program.

Infection Control must include:

  • The use of accepted standards of practice, including standard precautions, to prevent the transmission of infections and communicable diseases;
  • A method for identifying infectious and communicable disease problems;
  • A plan for the appropriate actions that are expected to result in improvement and provide infection control education to staff, patients, and caregivers.

That’s all for today.  Questions and comments may be posted below.

.  Stay tuned for more.

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