To help you prepare for the new Conditions of Participation, HEALTHCAREfirst has partnered with home health care consultant and regulatory expert, Mary St. Pierre, RN, BSN, MGA, for a series of blog articles regarding the regulatory changes to the CoPs that will likely require amended policies, procedures, and forms.

Part one of our series on the Home Health Conditions of Participation (CoPs) focuses on the establishment of a Quality Assessment and Performance Improvement Program or QAPI program. In this article, Mary sorts out the standards that are included in this part of the requirement, and provide suggestions on how to prepare. Please note that this is only a summary of many of the CoP changes and you should refer to the revised Conditions of Participation for complete details.

Standard: Develop, implement, evaluate, and maintain QAPI program
The new CoPs require that home health agencies develop, implement, evaluate, and maintain a QAPI program. Agencies must maintain documentary evidence of the QAPI program and be able to demonstrate and measure its operation to CMS. Additionally, there must be oversight by a governing body to ensure that the program:

  • Reflects the complexity of its organization and services
  • Involves all HHA services (including contracted)
  • Focuses on indicators related to improved outcomes including the use of emergency care services and hospital admissions/readmissions
  • Takes actions that address the HHA’s performance including prevention and reduction of medical errors

Standard: Program scope
The program scope standard requires the QAPI program be “capable of showing measureable improvement in indicators” that are linked to improvement in patient outcomes, safety, and care quality. Home health agencies will be required to measure, analyze, and track quality indicators. Quality indicators are defined in the CoPs as, “Specific, valid, and reliable measure of access, care outcomes, or satisfaction, or a measure of a process of care.” It includes identification of indicators that:

  • Will improve health outcomes, patient safety, and quality of care
  • Capable of showing measurable improvement in indicators
  • Measure, analyze, and track quality indicators
  • Include adverse patient events
  • Include aspects of performance that enable assessment of processes of care, services, and operations

Standard: Program data
Home health agencies must use the data collected to monitor the effectiveness of their services and to identify areas for improvement.

Standard: Program activities
The program activities standard describes the QAPI program activity requirements including:

  • Focus on high risk, high volume, or problem-prone areas
  • Consider incidence, prevalence, and severity of problems
  • Lead to an immediate of correction problems that do/have potential to threaten the health and safety of patients (immediate jeopardy)
  • Track adverse patient events
    • Analyze their causes
    • Implement preventive actions

Additionally, the QAPI program must have a plan to take actions aimed at performance improvement and to ensure that those improvements are sustained.

Standard: Performance improvement projects (July 13, 2018)
The CoPs also include a standard regarding performance improvement projects. To allow for agency’s to phase-in this standard, the compliance date is July 13, 2018. The standard requires that home health agencies:

  • Conduct performance improvement projects
  • Determine number and scope conducted annually based on
    • Scope
    • Complexity
    • Past performance
  • Document
    • Projects undertaken
    • Reasons for conducting projects
    • Measurable progress achieved

Standard: Executive responsibilities
This standard includes requirements for the QAPI governing body. It explains the role of the governing body:

  • Define implement, and maintain ongoing program for quality improvement and patient safety
  • Addresses
    • Priorities
    • Evaluation of improvement actions for effectiveness
    • Establishment, implementation, maintenance of clear expectations for patient safety
  • Appropriately address findings of fraud or waste

How can you prepare?

QAPI must be an ongoing process throughout your home health agency that oversees and documents the quality of care provided, including measuring your problems as well as your progress. Thorough documentation of your QAPI program, from inception through ongoing efforts is extremely important for program reporting, monitoring, and evaluation.

Review your current QAPI efforts and identify what pieces can stay as is, what should be modified, and what you need to add. Don’t wait! Start now so you have plenty of time to flesh out your QAPI program to ensure your success when the CoPs go into effect.

In the next blog article in this series, Mary will discuss infection control, care planning and coordination. Be sure to subscribe to get notifications when new articles in this series are posted!

Have questions about the new CoPs? Read our FAQ that addresses home health agencies’ most common questions and concerns.

HEALTHCAREfirst has created a helpful Home Health CoPs resource hub to give you the latest information through FAQs, guides, blog posts, and recorded webinars. This resource hub will be continuously updated as new information about the CoPs is released in order to make sure you have everything you need to be prepared.


About Mary St. Pierre, RN, BSN, MGA

Mary St. Pierre worked was employed as a registered nurse by the Visiting Nurse Association of Trenton and St. Francis Hospital in New Jersey, followed by 24 years as a home care nurse, clinical supervisor and branch manager with the Visiting Nurse Association of Washington, DC (now MedStar VNA).

Before retiring in 2013 she oversaw the operations of the Regulatory Affairs Department of the National Association for Home Care & Hospice (NAHC) for 20 years, tracking regulations and influencing regulatory bodies (e.g. CMS, FDA, OSHA). She wrote articles, prepared educational programs, presented speeches and programs and kept the NAHC membership abreast of regulatory, Medicare coverage, quality, and clinical information.

Since retirement, Mary has served as a consultant, providing clinical, operational, and regulatory guidance to the home health industry. She currently provides services exclusively to HEALTHCAREfirst.