{"ref":"GA-HH-QA-02","title":"Quality Assessment and Performance Improvement (QAPI)","category":"Quality","summary":"Sets up an ongoing, Agency-wide, data-driven quality assessment and performance improvement (QAPI) program that meets 42 CFR §484.65 for a Medicare-certified agency and is applied to the whole Agency as its own standard: a QAPI committee, quality indicators including OASIS outcomes and adverse events, immediate correction of threats to patient safety, performance improvement projects, and governing body oversight. It builds on the Georgia quarterly record review and annual evaluation in Policy GA-HH-QA-01.","inShort":["Our quality program measures how our patients do, such as hospital visits, falls, infections, and complaints, and works to improve the results.","If you see something that puts patients at risk, tell your supervisor or the Administrator right away. It will be fixed the same day.","Report every incident and mistake. We use reports to fix systems, not to blame people.","You may be asked to help with an improvement project. Your ideas from the field matter."],"primaryCitation":"42 CFR §484.65","citations":["Ga. Comp. R. & Regs. 111-8-31-.07(8)","Ga. Comp. R. & Regs. 111-8-31-.07(3)","Ga. Comp. R. & Regs. 111-2-2-.32"],"federalCitations":["42 CFR §484.65","42 CFR §484.65(c)(2)","42 CFR §484.65(e)","42 CFR §484.65(e)(4)","42 CFR §484.70(b)","42 CFR §484.45","42 CFR §484.105"],"surveyorAsks":["Show me your QAPI plan and the data you track. Who approved the frequency and detail of data collection?","What performance improvement projects did you run this year? Why did you choose them, and what measurable progress did you make?"],"forms":[{"ref":"GA-HH-QA-02-A","title":"Performance Improvement Project Charter"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.65; Ga. Comp. R. & Regs. 111-8-31-.07(8))","5. The QAPI Committee","6. What the Program Measures","7. Performance Improvement Activities","8. Performance Improvement Projects","9. Immediate Correction","10. Governing Body Responsibilities","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":"ga-hha","state":"Georgia","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}}