Nursing Home Quality Improvement Questionnaire

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C2-21-16

Baltimore, Maryland 21244-1850

Office of Clinical Standards and Quality/Survey & Certification Group

Dear Administrator:

We are pleased to announce that your facility has been selected to participate in a very important information gathering effort on behalf of the Centers for Medicare and Medicaid Services (CMS). Section 6102 (c) of the Affordable Care Act requires us to establish a quality assurance and performance improvement (QAPI) program and develop the tools and resources to assist nursing homes in meeting these new QAPI standards.

In order to improve the quality of the resources we provide to nursing homes, we have contracted with Abt Associates, Inc., and its subcontractor, the Colorado Foundation for Medical Care (CFMC), to administer a questionnaire. This effort will collect baseline information to identify performance improvement systems and processes that are currently in place and the extent to which they are functioning to help facilities identify and address quality issues. Questionnaires should be completed either by you, or another qualified individual. We anticipate that it will take approximately 20 minutes to complete the questionnaire. Your answers will become part of our ongoing efforts to develop effective QAPI tools that CMS will later provide to all nursing homes. Your

participation in this information gathering effort is extremely important.

The questionnaire is part of a multi-year demonstration program that will provide support to nursing homes that seek to strengthen their current quality improvement systems.

Abt, Inc. will collect all completed questionnaires; therefore, complete confidentiality of your individual responses will be maintained. To complete this questionnaire electronically, please go to (include url address) and enter the following PIN number, xxxxx. If you prefer to complete a printed copy of the questionnaire, we will mail one to your facility in approximately two weeks. We have enclosed additional information describing the QAPI initiative.

If you have any questions or comments about this questionnaire, please submit them to qapi@abtassoc.com . We will answer your questions as quickly as possible.

Sincerely,

Thomas E. Hamilton

_Director

Enclosure