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Quality measures are used to gauge how well an “Entity” provides care to its patients. Linking Value-based programs that reward health care providers with incentive payments for the quality of care they give to people. The introduction of §483.75 Quality Assurance and Performance Improvement insures all facilities develop, implement and maintain effective and comprehensive, data-driven QAPI programs that focuses on system(s) of care, outcome(s) of care and quality of life.This Webinar will focus on developing, implementing and maintaining effective and comprehensive, data-driven QAPI programs within Healthcare Food and Nutrition operations, for Hospital’s Dietary Service operations, and November 2019 Implementation, Behavioral Health Centers that focuses on supporting The Entities systems of care, outcomes of care and quality of life.


  • § 483.75 Quality assurance and performance improvement(a) Quality assurance and performance improvement (QAPI) program. Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must –
  • Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities; • Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;
  • §483.25(g)(1)(3), 483.25(g)(2), Quality of care
  • Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices. Including Tags (F241, Dignity, F242, Self-determination and Participation, F272…
  • §483.15 Quality of Life (Food and Nutrition Services The facility must promote care for residents in a manner and in an environment, that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality. Promoting resident independence and dignity in dining

The Centers for Medicare & Medicaid Services (CMS), in collaboration with public and private partners, are transforming how they conduct business and operations, connecting providers, and empower consumers and their beneficiaries. Driving quality improvements are a core function of CMS. This commitment is evident as CMS enhances its partnerships in a delivery system where providers are supported in achieving better outcomes in health and health care at lower cost for the beneficiaries and communities they serve. CMS strategically implemented these efforts to ensure that providers meet their goals, quality of life improves for beneficiaries and consumers, and patients receiving care are healthy and safe”.This Webinar purpose is to serve as an Annual Refresher/Introduction to changes, as of November 2016, for Food and Nutrition Services, Quality Assurance and Performance Improvement Projects for Long Term Care, Hospitals Healthcare Operations, as well as to “Introduction to” “Compliance”, and Implementation for Behavioral Health Centers, §483.60 Food and Nutrition Service (November 2019). This Webinar sets the stage for Administrators, Directors, Managers and Staff on (CMS) Guidelines for §483.75Quality Assurance and Performance Improvements, Tags (F520, F692, F693, F694) effective November 28th, 2017, and Behavioral Health Services organizations (November 2019).


  • Discover How Implement Food and Nutrition Services QA Projects
  • (4) Present documentation and evidence of ongoing QAPI program’s implementation and the facility’s compliance with requirements to a State Survey Agency, Federal surveyor or CMS upon request.
  • (b)Design Programs, and scope. A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:
  • (1) Address all systems of care and management practices (Food and Nutrition Services)
  • (2) Include clinical care, quality of life, and resident choice;
  • (3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.
  • (4) Reflecting on the complexities, uniqueness of care, and services that the facility provides.
  • (c)Program feedback, data systems and monitoring. A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, Quality of Care and Quality of Life. Tools for Food, Dining Service Directors, Managers
  • Based on a 2010 survey 40 percent of the 15,000 long term care facilities failed to meet the bases of 42 CFR. This Webinar will focus on the opportunity for Food Service Operations to better perform within the intended guidelines, as well as understand and interpret intent regulation intent.
  • This webinar may also be used as a means to introduce to managers “Methods”, “Tools”, “Best Practices” for facilities, managers who want to perform higher in the Quality Outcomes. Hospital’s Quality Initiative (HQI), most notably from the Hospital Compare website. These type of quality measures are used in other CMS hospital quality initiatives, requiring all healthcare organizations to both measure, put in place quality improvement measures with similar outcomes
  • Actual Tools Offered.
  • Slides Presentation of Manager Training on CMS Guidelines Quality Indicators.
  • Online sources “States Guidance to Surveyors for Long Term Care Facilities, ”
  • Online source of “Actual Forms” (actual inspector notes/inspection)
  • Tools Used in Food Service Audit/Survey, Operation, documents, correct actions, improve overall quality of life for residence
  • Food and Nutrition Services Dining Observations
  • Monthly Meal Quality Review
  • Monthly Sanitation/Infection Control Review
  • Meal Audit Tool
  • Kitchen/Food Service Observation
  • Tools designed to discover how to best use and keep your operation Deficiency Free
  • Food Service Audit Tool
  • Meal Temperature Logs
  • Tray Accuracy Tool
  • Test Tray Audit Tool
  • Mock Survey
  • Quality Indicators that have corrected Deficient Outcomes in the past.

  • Administrators who want a better understanding of survey team approach for Quality Indicators for their food operations
  • Dining Service Directors, Managers
  • QAPI Team, Team Leaders
  • Assisted Living, Home Health Agencies
  • Nursing Homes
  • Hospitals
  • Behavior Health Service, Allied Health Organizations

Lisa Marsden is the President and Founder of Coulter Strategic Services. Coulter Strategic Services provides Financial Advisors and compliance consulting firms with compliance and project management services, allowing the advisor to focus on what they do best, provide their client’s with exceptional financial services. Coulter Strategic Services also provides customized compliance training. Prior to starting her own firm, Ms. Marsden was a partner and member of the C-Suite at Financial Advisory Firms in Boca Raton Florida. She has been in the financial services industry for over 25 years. Ms. Marsden has a degree in computer programming from Keiser University, and holds the Investment Advisor Certified Compliance Professional Designation and Claritas ® Investment Certificate, issued through the CFA Institute.

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