Content contained in this newsletter may have been previously published in prior issues of the QCC newsletter.
QIO - HSAG logos


The Florida Nursing Home
Quality Care Connection
Nursing Home Event Icons
Be a Continuous Learning Organization
To improve resident care, it is important to proactively identify issues. A continuous learning organization is one that knows where it stands with regard to key metrics and outcomes; knows when and how to change in order to meet goals and expectations; uses data to drive performance; and views itself as an interdependent system (one in which the people, structures, supplies, and resources come together to make the organization function).

Change Concepts of this strategy include:
  • Making systems-thinking the norm.
  • Tracking your progress.
  • Planning and implementing tests of change.
For more insight and practical tips,
read pages 22-25 of the National Nursing Home Quality Care Collaborative Change Package.
Contact us with any questions at
Ideas for Residents with Depressive Symptoms
The quality measure (QM) for Residents Who Have Depressive Symptoms (Long Stay) reports the percentage of long-stay residents who have had symptoms of depression during the two-week period preceding the minimum data set (MDS) 3.0 target assessment date. Learn more about the calculation of this QM in the MDS 3.0 Quality Measures User's Manual (v10.0).

Central to this measure is the resident's:
  • Interest and pleasure in doing things
  • Feelings of being down, depressed, or hopeless
Because of the complexity in the Resident Mood Interview, it is important to ensure the interview is resident-focused. In other words, plan the resident interview for a time when the resident is most alert and objective about his or her needs.

Performance Improvement Project (PIP) teams should:
  • Identify which residents have triggered this measure.
  • Review and revise their care plans accordingly.
  • Address the ways in which the organization delivers care that is individualized and person-centered.
For example, effective communication by nursing home staff members is related to a decrease in depression among residents. Communications skills training may be an effective, resident-centered approach to improving this important QM .

Next month: Tips and change ideas for decline in activities of daily living.
QAPI Corner
Step 5: Develop your QAPI plan
In July 2015, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that revises the requirements for long-term care facilities. Nursing homes will need to submit a QAPI Plan that describes how QAPI will be implemented.  

According to the CMS final rule to Reform the Requirements for Long-Term Care Facilities, nursing homes must have a QAPI plan in place by November 28, 2017, and full implementation of QAPI by November 28, 2019. Read more about these changes.  

For more information about developing a QAPI plan, read page 13 of QAPI at a Glance. In addition, the tool provided on page 34 provides a template guide for developing a QAPI plan.
Next month: Conduct a QAPI Awareness Campaign
Clostridium difficile Infection (CDI) Prevention Cohort Members

Announcements and Information

  • National Healthcare Safety Network (NHSN) Annual Facility Survey is due by March 1, 2017.
  • To submit your Annual Facility Survey for calendar year 01/01/2016 to 12/31/2016, login to the NHSN using your Secure Access Management Services (SAMS) grid card credentials.
  • HSAG recommends printing a copy of your completed 2015 Annual Facility Survey that was completed during the enrollment process to use as a reference when completing the 2016 survey, as most of the information will be the same.
  • To print a copy of your 2015 Annual Facility Survey, log into NHSN using your SAMS grid card credentials, select the "Surveys" tab on the left navigation bar, select "Find", select 2015 from the "Survey Year" drop-down menu, select "Find", then select "Print Form." 
  • To submit the 2016 Annual Facility Survey, select the "Surveys" tab on the left navigation bar select "Add", select 2016 for the "Survey Year", and enter your facility data. Mandatory fields are marked with an asterisk (*). Do not forget to select "Save" at the end of the survey. 
  • CDI data for February due by March 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 of February.
  • Resolve Alerts: Review the "Alerts tab and complete missing and/or incomplete data.
Additional Resources

Upcoming Event
NHSN Training Webstream Information
NHSN LTCF Training Course
March 20, 2017 at 9 a.m. EST
Agenda and instructions on how to view the webstream available at:
HSAG Resource Spotlight
Access all of the CMS tools for QAPI from one easy-to-use electronic resource library. Learn More.

This template helps 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 actions steps of developing your organization's QAPI plan.  Learn More.
Upcoming Event

USF Byrd Alzheimer's Institute
19th Annual Geriatric Health Care Conference
Tampa, FL
June 13 to 15, 2017
Have you completed your QAPI Self-Assessment? 
New Web Resources!

Quick Links


Access archived issues of the QCC newsletter at: