{"ref":"CA-HH-QA-02","title":"Quality Assessment and Performance Improvement (QAPI)","category":"Quality","summary":"Sets the Agency’s quality assessment and performance improvement (QAPI) program: an effective, ongoing, agency-wide, data-driven program that the governing body oversees, that measures and tracks quality indicators (including OASIS-based measures and adverse patient events), focuses on high risk, high volume, and problem-prone areas, corrects threats to patient safety at once, runs documented performance improvement projects each year, and sustains improvement. Required by 42 CFR §484.65 if the Agency is Medicare-certified and applied to all patients as the Agency’s own standard, integrated with the California quality management system (22 CCR §74742).","inShort":["The Agency tracks how patients are doing, such as hospital visits, falls, infections, and missed visits, to find where care can improve.","Report every incident and near miss. That data drives the improvement work.","Problems that put a patient’s safety at risk are fixed right away, not saved for a meeting.","Each year the Agency runs improvement projects and measures whether they worked.","Ask your supervisor about current projects and share your ideas."],"primaryCitation":"42 CFR §484.65","citations":["22 CCR §74742","22 CCR §74721(c)(6)","22 CCR §74718(a)(3)"],"federalCitations":["42 CFR §484.65","42 CFR §484.65(a)","42 CFR §484.65(b)","42 CFR §484.65(c)","42 CFR §484.65(d)","42 CFR §484.65(e)","42 CFR §484.70(b)","42 CFR §484.105(a)"],"surveyorAsks":["Show me your QAPI program. What quality indicators do you track, and who approved how often data are collected?","What performance improvement projects did you run this year? Why did you choose them, and what measurable progress did you make?"],"forms":[{"ref":"CA-HH-QA-02-A","title":"Performance Improvement Project Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.65)","5. Program Scope","6. Data","7. Improvement Activities","8. Performance Improvement Projects","9. Governing Body Responsibilities","10. Annual Program Evaluation","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"ca-hha","state":"California","service":"Home health","guides":[{"path":"/guides/home-health-qapi/","h1":"What is QAPI in home health, and what does §484.65 require?"},{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}