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Jonathon E. Cohn, Partner, Arent Fox LLP Annie Chang Lee, Associate, Arent Fox LLP

CMS Finalizes Quality Assessment and Performance Improvement (QAPI) Worksheets

By Jonathon E. Cohn, Partner, Arent Fox LLP
By Annie Chang Lee, Associate, Arent Fox LLP

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Original Publish Date: January 7, 2016

CMS has finalized surveyor worksheets for assessing a hospital’s compliance Quality Assessment and Performance Improvement (QAPI). This worksheet will be used by State and Federal surveyors on all survey activity in hospitals when assessing compliance the Conditions of Participation regarding QAPI. As of late 2014, the Final Worksheets were made publicly available. This article will briefly describe the finalized QAPI Worksheet and what this Guidance means for hospitals and providers that render lower levels of care.

QAPI Worksheet

By way of background, in 2003, CMS issued a final rule requiring all hospitals that participate in the Medicare/Medicaid programs to develop and maintain as a condition of participation a QAPI program. In essence, the regulation requires that hospitals must establish a data-driven QAPI program that involves all hospital departments and services and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. See 42 C.F.R. §482.21.

The finalized QAPI Worksheet is a detailed 15 pages, broken down into separate parts, of items that will be assessed during on-site surveys for QAPI compliance. Below is a brief description of each subsection of the QAPI Worksheet:

For the complete QAPI Worksheet, please refer to:

What This QAPI Worksheet Means for Providers

Document everything! As you can see, other than developing a QAPI program that adheres to all of the requirements in the QAPI Worksheets, the hospitals must document everything so it can provide the surveyor tangible evidence to show it complied with each item in the QAPI Worksheet.

As with any guideline that CMS issues to the public, the guidelines are not mandatory, per se. However, it would be prudent for hospitals to develop its QAPI program to follow these guidelines as these will be the criteria surveyors use when assessing whether the hospital is in compliance with CMS’ rules and regulations. Regarding the newly finalized QAPI worksheets, CMS states, “[t]he hospital industry is encouraged, but not required, to use the worksheets as part of their self-assessment tools to promote quality and patient safety.”

Note that this QAPI Worksheet currently only applies to hospitals. However, it is safe to assume that these requirements will trickle down to facilities that provide lower levels of care. Therefore, it is never too early to start developing a QAPI program that incorporates the requirements in CMS’ QAPI Worksheet.

Jonathon E. Cohn is a partner in the health care practice of Arent Fox LLP. His practice is devoted to litigation and trial work with an emphasis on health care issues including long-term care, Medicare and Medicaid, fraud and abuse, and reimbursement disputes. Jon represents various long-term and acute care providers in many areas, including licensing, certification, civil and criminal enforcement, reimbursement and collections, and other regulatory and administrative proceedings. He also represents health care professionals in licensure and workers’ compensation proceedings. He can be reached at 213-443-7515 or

Annie is an associate in the Los Angeles office, where she is a member of the Health Care Practice Group. She focuses on complex civil litigation cases involving health care reimbursement issues. She represents major health care providers in state and federal civil actions, arbitrations, mediations, and settlement negotiations. She can be reached at