Quality Assurance and Performance Improvement- Phase 3
LPN / LVN
Other IDT Member
1. True or False: Each facility must develop, implement, and maintain an effective, comprehensive, data‐driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life.
2. Demonstration of compliance includes all of the following, EXCEPT:
A. Evidence of systems and reports demonstrating identification, reporting, investigation, analysis and prevention of adverse events.
B. Data collection and analysis at regular intervals.
C. CMS mandated data collection tools.
D. Documentation demonstrating development, implementation and evaluation of 3 corrective actions or performance improvement activities.
3. True or False: Each facility must present its QAPI plan to State and Federal surveyors at each annual recertification survey and upon request during any other survey, and to CMS upon request.
4. Which new staff member role has been added as a required member of the facility QAPI team by the Phase 3 Requirements of Participation?
B. Infection Preventionist
C. Social Worker
D. Chair of Resident Council
5. True or False: If the facility’s infection control data indicates that staff may not have responded in a timely and effective manner to address an outbreak of a communicable disease, the facility must allow the surveyor to review and copy QAA committee minutes and related documentation so that the surveyor is capable of evaluating the facility’s QAPI/QAA compliance.
6. What is the minimum number of Performance Improvement Projects that must be completed to meet the Phase 3 Requirements of Participation?
A. Two PIPs per year at least one month apart.
B. One PIP per year.
C. One PIP per quarter.
D. No minimum number of PIPs identified in the Requirements of Participation.
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