Focus on the F Tag: Phase III is coming SOON!

Key changes within Phase III are related to QAPI requirements and advance QAPI from a plan to a fully operational system of ongoing organizational learning and improvement.  The combination of the new requirements with existing concerns listing QAPI as one of the top 10 F-Tags received by organizations during licensure surveys in 2018 results in a strong impetus to spotlight QAPI. 
Additional requirements for QAPI in Phase III include the following:
· 483.70 Administration (d)(3) Governing Body Responsibility of QAPI Program
· Interpretation: QAPI is at the level of the Board of Trustees (or governing body).  The analogy would be “getting Boards on board with QAPI.”  The governing body is responsible and accountable for QAPI.
· 483.12 Freedom from Abuse, Neglect, and Exploitation (b)(4) Coordination with QAPI Plan
· Interpretation: QAPI is involved in review of allegations/incidences of abuse, neglect and exploitation.
· 483.21 Comprehensive Person-Centered Care Planning (b)(3)(iii) Trauma Informed Care
· Interpretation: Person-centered, trauma informed care is a component of the QAPI process.
· 483.75 Quality Assurance and Performance Improvement (g)(1) QAA Committee the addition of the Infection Control Preventionist/Officer (ICPO)
· Interpretation: The infection control preventionist is a member of the QAA committee.
Staff Contact: Danielle Watford, Director of Quality Improvement & Regulatory Affairs