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Getting Back to Basics – Maintaining Regulatory Compliance; A QAPI Approach

Educational Session

June 9, 2023 @ 10:15 am - 11:45 am EDT

Maintaining nursing home regulations and compliance can overwhelm even the most prepared facility – and that task has become more daunting since the final Rules of Participation (RoP) mandates were put into action. Care providers were forced to examine policy and procedures, while ensuring all components of regulations were being completed. Thanks to an unprecedented staffing crisis, providers are scrambling to adhere to rapidly evolving guidance. To comply with CMS regulations moving forward, operators must “get back to the basics” in preparing for compliance surveys and other state and federal rules. Facilities must be ready to show surveyors how they identify, respond to, and mitigate different types of risk.

Establishing a culture of compliance requires organizational leadership; facilities must have competent awareness of the state surveyors’ expectations and remain apprised of upcoming regulatory changes. This session explores how nursing operators can leverage live post-acute analytics, pulled directly from EHRs, to meet state and federal requirements, prepare for regulatory reporting and onsite surveys, conduct infection surveillance, and mitigate risk. Highlighting the seven key areas of compliance associated with the surveyors’ process – from offsite survey preparation to the exit conference – this presentation highlights the key, automated data points and processes SNFs can use to demonstrate compliance. The session will also explore best practices on how to collect and use live data within the EHR to evaluate the quality of care being provided to patients, as well as to develop and monitor facility-wide performance improvement processes.

Learning Objectives

  • Understand how post-acute analytics can be incorporated into daily clinical processes and operations to maintain regulatory compliance
  • Establish live data-driven standardized care pathways to prioritize care and reduce administrative burdens, while addressing state and federal requirements
  • Identify quality improvement practices to enhance care, achieve compliance, and better prepare for surveys


  • Kathy Derleth, RN, BSN, Clinical Program Director, Real Time Medical Systems
  • Debra Wright, RN, BSN, RAC-CT, Quality Improvement Specialist, Quality Insights

This session is presented as part of the PANAC 25th Annual Conference.

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