Content contained in this newsletter may have been previously published in prior issues of the QCC newsletter.  
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The Florida Nursing Home
Quality Care Connection
This QCC Newsletter is your monthly National Nursing Home Quality Care Collaborative (NNHQCC) in Florida member update that provides information on the latest activities. It is a quick reference for information on upcoming learning events, links to improvement tools, resources, news, best practices, and success stories. 
Healthcare-Acquired Infection
Prevention Strategies
According to the Office of Disease Prevention and Health Promotion (, healthcare-acquired infections (HAIs) are infections that can be acquired while a patient is receiving treatment for another condition in a healthcare setting. HAIs can be acquired anywhere healthcare is delivered and can be caused by any infectious agent, including bacteria, fungi, and viruses.

To help nursing homes prevent healthcare-acquired infections, the National Nursing Home Quality Care Collaborative (NNHQCC) Change Package includes a six-point change bundle to help the multi-disciplinary quality improvement team support the function and well-being of residents. The six-points are as follows:

  1. Promote hand hygiene.
  2. Prevent transmission of infections by staff members.
  3. Prevent transmission of infections by all persons.
  4. Establish and implement system-wide environmental cleaning policies.
  5. Identify and treat infections appropriately.
  6. Avoid indwelling catheter use unless appropriately indicated.

You can find specific action items for each of these six points in Attachment 4 of the  NNHQCC Change Package.

This site is an introduction to a set of training sessions aimed to provide nursing home leaders with training materials that can be used to enhance understanding of important concepts and practices that promote stewardship and C. difficile prevention, and provide information, tools, and resources.
Tips for Improving the Weight Loss
Long-Stay Quality Measure
This measure reports the percentage of long-stay residents who had a weight loss of 5 percent or more in the last month, or 10 percent or more in the last two quarters who were not on a physician-prescribed weight-loss regimen noted in a minimum data set (MDS) assessment during the selected quarter.

When you are working with your staff members, you may want to consider the following questions.
  • Do staff understand the RAI coding definition if he/she is coding this section of the MDS?
  • Are the scales calibrated at least monthly for accuracy?
  • Are staff members checked for proficiency in performing weigh-ins?
If you would like more improvement tips and MDS coding insight, you can download the HSAG Weight Loss quality measure tip sheet by  clicking here .
This manual contains detailed specifications for the MDS 3.0 quality measures.

Please contact  if you have any questions.
QAPI Corner
Suggestions for Implementing QAPI Steps:

Now that we have gone through all 12 steps of QAPI, here are some suggestions to help you implement this program.

  • Define and promote leadership responsibility and accountability for your home. Leadership is key to promoting, instituting, and sustaining a QAPI program in your home.
  • Take your QAPI "Pulse" with a Self-Assessment. Discover where your home is with QAPI implementation. You can complete a QAPI self-assessment here.
  • Identify your organization's guiding principles to guide your decision making and help you set priorities.
  • Conduct a QAPI awareness campaign. Everyone should know about your home's QAPI program.
  • Develop a strategy for collecting and using QAPI data. It's difficult to show improvement if you don't measure it.
  • Conduct a root cause analysis and choose actions that are linked to the root causes and that lead to a system or process change.

You can find more suggestions in the  National Nursing Home Quality Care Collaborative Change Package .

This document offers a template to assist your facility in creating a QAPI plan that will guide your organization's performance improvement efforts. A facility QAPI Plan is required as part of Phase 2 implementation of the Reform of Requirements for Long-Term Care Facilities, effective November 28, 2017.
Have You Completed Your QAPI Self-Assessment?
Clostridium difficile Infection Prevention Cohort Members
Announcements and Information

  • CDI data for September is due October 10, 2017.
  • Login to NHSN using your SAMS grid card credentials to submit your CDI LabID events (if applicable) and summary data (total resident days for the month, resident admissions, and residents admitted on CDI treatment).
  • Do not forget to check "Report No Events" under the C. difficile row if there were no positive labs collected within your facility for the month.
  • Resolve Alerts: Review the "Alerts tab and complete missing and/or incomplete data.
Upcoming Events and Education
Thursday, October 5, 2017
2 to 3:30 p.m. ET
Webinar: Enhancing the Quality of Sleep; Can it Reduce Antipsychotic Drug Use?
Join HSAG, the California Partnership to Improve Dementia Care, your peers, and Sue Ann Guildermann, RN, MA, director of education and quality improvement, Empira, for this educational webinar. The event is open to all FL NNHQCC members.

Continuing Education: Health Services Advisory Group, Inc. is the CE provider for this event. Provider approved nationally for all nurses by the Board of Registered Nursing, Provider Number 16578, for 1 .5 contact hours. Pending approval. Florida Board of Clinical Social Work, Florida Board of Nursing, Florida Council of Dietetics and Nutrition, Florida Board of Nursing Home Administrators and Florida Board of Pharmacy for 1 Contact Hour. (CE Broker #20-578141) There is no charge for attendance of this event.
HSAG Resource Spotlight
This infographic outlines the 5 steps to prevent healthcare-associated infections in nursing homes from the National Nursing Home Quality Care Collaborative (NNHQCC) Change Package.   Learn more .

Effective November 28, 2018, the new long-term care regulations require nursing facilities to conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents (§483.70(e)). This is an optional template provided for nursing facilities to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require . If used, this tool may be modified. Each facility has flexibility to decide the best way to comply with this requirement.
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. FL-11SOW-C.2-09222017-01