{"ref":"FL-HH-QA-01","title":"Quality Assurance Program and Quarterly Clinical Record Review","category":"Quality","summary":"Sets up the quality assurance program that Rule 59A-8.0095(2)(e), F.A.C., requires the director of nursing to establish and conduct: a documented review, at least quarterly, of a sample of both active and closed clinical records against the seven assurances the rule lists, the indicators the Agency tracks, how findings become corrective action plans, how medication errors and incidents feed the program, and how results reach the Administrator and the governing body. If the Agency is Medicare-certified, this program is run as one program with the QAPI program in Policy FL-HH-QA-02.","inShort":["Every quarter the director of nursing, or a delegate, reviews a sample of open and closed patient records.","Complete, legible, dated, and signed notes are what the review checks most.","If a review finds a risk to a patient, it is fixed the same day.","Report every medication error and incident. They are reviewed to stop them happening again.","When a review leads to a change in how we work, you will be told and trained."],"primaryCitation":"Rule 59A-8.0095(2)(e), F.A.C.","citations":["Rule 59A-8.0095(2)(e), F.A.C.","Rule 59A-8.002(25), F.A.C.","s. 400.497(5)(c), F.S.","Rule 59A-8.0219(6), F.A.C.","Rule 59A-8.0248(4)(a), F.A.C.","s. 400.476(2), F.S.","Rule 59A-8.022, F.A.C.","s. 400.487(1), F.S.","s. 400.494, F.S."],"federalCitations":["42 CFR §484.65"],"surveyorAsks":["Show me the documentation of your quality assurance record reviews for the last four quarters. Which active and which closed records were reviewed, and by whom?","Who is responsible for the quality assurance program? If the reviews were done by a delegate, show me the director of nursing's delegation."],"forms":[{"ref":"FL-HH-QA-01-A","title":"Quarterly Clinical Record Review Tool"},{"ref":"FL-HH-QA-01-B","title":"Quality Assurance Quarterly Summary Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (Rule 59A-8.0095(2)(e), F.A.C.)","5. Roles in the Program","6. The Quarterly Clinical Record Review","6.1 Sample","6.2 What the reviewer checks","6.3 Immediate problems","6.4 Scoring and documentation","7. Quality Assurance Committee","8. Indicators the Agency Tracks","9. Medication Errors and Incidents","10. Corrective Action Plans","11. Reports, Annual Evaluation, and Work Plan","12. Confidentiality of Quality Records","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"fl-hha","state":"Florida","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}}