06/12/2025

Survey Tip of the Week: Sustained Improvement

During this week’s Survey Tips and Tactics (STAT) call, participants reviewed recent citations and the updated requirements for Quality Assurance and Performance Improvement (QAPI). Under §483.75(d)(1), nursing homes are required to implement actions to improve performance, measure the success of those actions, and track performance over time to ensure improvements are both achieved and sustained. Recent citations have been issued to facilities that failed to demonstrate an effective quality assurance program, particularly when similar deficiencies were cited during consecutive annual surveys.

As part of the QAPI program, the facility must develop and implement policies and procedures that address:

• How it will use systematic approaches (such as root cause analysis, reverse tracker methodology, or health-care failure and effects analysis) to assist in determining underlying causes of problems impacting larger systems.
• How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
• How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

LeadingAge Ohio recommends reviewing prior citations and plans of correction to verify that audits were completed as scheduled, and results were reviewed by the QAPI committee. This helps ensure not only compliance, but also that improvement efforts are effective and long-lasting.

LeadingAge Ohio has provided survey tips to help navigate the changes in the revised QSO-25-14- NH memo. An archive of survey tips can be accessed on the LeadingAge Ohio webpage within the Communications menu, under The Source tab.

CMS has updated the survey resources on the CMS Nursing Home webpage in accordance with the revised QSO-25-14- NH memo. LeadingAge Ohio encourages facilities to monitor compliance using the surveyor guidance found in the State Operations Manual Appendix PP . Additionally, the survey pathways can be found in the Survey Resources zip file on the CMS Nursing Home webpage and under the downloads section on this CMS webpage. LeadingAge has developed webinars and resources on the requirements of participation which are located on the LeadingAge learning hub. LeadingAge continues to add QuickCasts on the regulatory groups. Updated resources have also been added on the Nursing Home RoP Tools and Resources webpage.

For more information about the requirements of participation and citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the July 7 call at 11:00AM. LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you would like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.