Section R414-516-3 - Quality Improvement Program Requirements of Participation(1) A program is required in six of nine metrics to:(a) score better than the national average;(b) improve from the earlier state fiscal year (SFY); or(c) not receive a state survey deficiency of F, H, I, J, K, or L.(2) The metrics and state survey used for the QI Program are in accordance with the following data:(a) CASPER percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine;(b) CASPER percentage of long-stay residents with a urinary tract infection;(c) CASPER percentage of high-risk long-stay residents with pressure ulcers;(d) CASPER percentage of long-stay residents experiencing one or more falls with major injury;(e) CASPER percentage of long-stay residents who lose too much weight;(f) CASPER percentage of long-stay residents who receive an antipsychotic medication;(g) CASPER percentage of long-stay residents whose ability to move independently worsens;(h) adjusted nursing staff hours for each resident each day; and(i) state survey without a quality of care deficiency of F, H, I, J, K, or L.(3) If CMS modifies or removes a metric for any state fiscal year (SFY), the department shall notify the facilities and consider the metric as achieved for the facilities.(4) If state licensing does not conduct a survey for a program in any given SFY, then the survey requirement described in Subsection (2)(i) of this section is removed from consideration, and the facility must meet five of eight metrics.(5) If more than one survey is completed during the QI SFY, then all surveys are used for the period.(6) The source of data used to calculate compliance comes from the CMS website, except for data described in Subsection (2)(i), which comes from state licensing. The data that represent the SFY are used for the analysis. Each program provides data to CMS for nursing hours and CASPER. The data is then made available in the subsequent SFY and downloaded by DIH.(7) DIH does not require a provider that enters the NF NSGO UPL program for only part of an SFY, based on provider participation start date, to comply with the QI requirements described in Subsection (2) in the first SFY.Utah Admin. Code R414-516-3
Adopted by Utah State Bulletin Number 2018-2, effective 1/1/2018Amended by Utah State Bulletin Number 2019-1, effective 12/6/2018Amended by Utah State Bulletin Number 2019-8, effective 3/21/2019Amended by Utah State Bulletin Number 2019-18, effective 8/29/2019Amended by Utah State Bulletin Number 2022-02, effective 12/29/2021Amended by Utah State Bulletin Number 2024-14, effective 7/1/2024