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. 
Have you Reviewed Your Nursing Home's Current Quality Measure Composite Score?
The Quality Measure Composite Score, developed by the Centers for Medicare & Medicaid Services (CMS), comprises 13 long-stay measures and is an excellent "barometer" of your facility's performance. The CMS goal is for nursing homes to achieve a Composite Score of 6 percent or less.
For more information, please read the NNHQCC Quality Measure Composite Score handout at:   

The most current (October 2016 to March 2017) Quality Measure Composite Score report was mailed to Florida NNHQCC members at the end of the July 2017 month.

Given the Composite Score data is always six months old, the best way to access more recent Quality Measure data is to reference the MDS 3.0 CASPER Report.
Long-Stay Influenza Vaccine Quality Measure Overview
Importance of Section O (Influenza Vaccine)

Health-related quality of life and planning for care are two important rationale for coding Section O (Influenza Vaccine). When infected with influenza, older adults and persons with underlying health problems are at increased risk for complications and are more likely than the general population to require hospitalization. Influenza vaccines have been proven to be effective in preventing hospitalizations.
Steps for Assessment
  1. Review the resident's medical record to determine whether an influenza vaccine was received in the facility for this year's influenza vaccination season.
    If vaccination status is known, proceed to the next step.
  2. Ask the resident if he or she received the influenza vaccine outside of the facility for this year's influenza vaccination season. If vaccination status is still unknown, proceed to the next step.
  3. If the resident is unable to answer, then ask the same question of the responsible party/legal guardian and/or primary physician. If influenza vaccination status is still unknown, proceed to the next step.
  4. If influenza vaccination status cannot be determined, administer the influenza vaccine to the resident according to standards of clinical practice.

Coding Tips and Special Populations

  • Once the influenza vaccination has been administered to a resident for the current influenza season, this value is carried forward until the new influenza season begins.
  • Influenza can occur at any time, but most influenza occurs from October through May. However, residents should be immunized as soon as the vaccine becomes available and continue until influenza is no longer circulating in your geographic area.

More information

CMS Releases New Appendix PP

Interpretive Guidance for Phase II

Revised Medicare and Medicaid requirements for Long Term Care (LTC) facilities was released September 28, 2016 and became effective as of November 28, 2016, with a three part phase-in of implementation dates over the next three years. The implementation for Phase 2 of the revisions is Nov. 28, 2017. CMS survey-and-certification memo S&C: 17-36-NH gives providers critical information about how to prepare for these changes that are required under Phase 2 of the roll-out of the Reform of Requirements for Long-term Care Facilities updating the Medicare/Medicaid conditions of participation. This information includes a State Operations Manual (SOM) Appendix PP for Phase 2 of 696 pages of revisions to the F-tags and the Interpretive Guidance in Appendix PP, Guidance to Surveyors of Long-term Care Facilities,of the State Operations Manual. The Appendix PP revisions include new guidance for multiple F-tags, not just the Phase 2 regulatory changes.  

QAPI Corner
STEP 11: Getting to the "Root" of the Problem

A major challenge in process improvement is getting to the root of the problem or opportunity.


Root cause analysis (RCA) is a term used to describe a systematic process for identifying contributing causal factors that underlie variations in performance. This structured method of analysis is designed to get to the underlying cause of a problem - which then leads to identification of effective interventions that can be implemented in order to make improvements.


RCA helps teams understand that the most immediate or seemingly obvious reason for the problem or an event may not be the real reason that an event occurred. The RCA process leads to digging deeper and deeper - looking for the reasons behind the reasons. This process will generally lead to the identification of more than one root cause.  The root cause(s) and any contributing factors can then be sorted into categories to facilitate the identification of various actions that can be taken to make improvements.


RCA focuses primarily on systems and processes, not individual performance.


The RCA process takes practice, but can be a valuable tool for performance improvement. In order to get familiar with RCA you and your team may consider:

  • Studying case examples of RCAs.
  • Applying RCA to an adverse event and discussing this technique with the team.
  • Building RCA examples into training opportunities.

For more information on this topic,

read page 18 of QAPI at a Glance.

Next issue: Take Systemic Action
Have You Updated Your QAPI Self-Assessment?
Clostridium difficile Infection Prevention Cohort Members
Announcements and Information

  • CDI data for July is due August 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
Wednesday, August 30, 2017
Antibiotic Stewardship National LAN Event 
Sunrise; Wednesday, September 6, 2017
Tampa; Tuesday, September 12, 2017
Orlando; Thursday, September 14, 2017
Tallahassee; Monday, September 18, 2017
FL-NNHQCC Learning Session 2 2017 Joint Training
Skilled Nursing Facilities
HSAG Resource Spotlight
Access all of the CMS tools for QAPI from one easy-to-use electronic resource library. Learn more .
This QAPI Plan Template can help guide nursing home staff members as they develop specific quality improvement plans for their organizations. Learn more .
This guide helps walk your team through the action steps of developing your organization's QAPI plan. Learn more .

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.2-07242017-01