{"ref":"GA-HSP-QA-01","title":"Quality Management, Utilization and Peer Review (QAPI)","category":"Quality","summary":"Sets out the Agency’s quality management, utilization and peer review program: the interdisciplinary committee and the person the governing body appoints to lead it, the written criteria and the ten systematic reviews Georgia requires, how adverse events and incidents are reported on Form GA-HSP-QA-01-A, performance improvement projects, hospice quality reporting to CMS, the annual evaluation for the medical staff and governing body, and confidentiality.","inShort":["Lee Sample leads our quality management, utilization and peer review program.","Report every fall, medication error, injury, near miss or other incident on the incident report before the end of your shift.","Make the patient safe first, then call the on-call nurse or 911.","Incident reports do not go in the patient record. Record only the facts and the care given.","Complaints and on-call logs are reviewed by the committee at every meeting."],"primaryCitation":"Ga. Comp. R. & Regs. 111-8-37-.09","citations":["Ga. Comp. R. & Regs. 111-8-37-.09","Ga. Comp. R. & Regs. 111-8-37-.07(5)(g)","Ga. Comp. R. & Regs. 111-8-37-.06(3)","Ga. Comp. R. & Regs. 111-8-37-.12(a), (c)","Ga. Comp. R. & Regs. 111-8-37-.16(1)","Ga. Comp. R. & Regs. 111-8-37-.17(2)(d), (4)(b)","Ga. Comp. R. & Regs. 111-8-37-.18(1)(c)","O.C.G.A. §31-7-130 et seq."],"federalCitations":["42 CFR §418.58","42 CFR §418.54(e)","42 CFR §418.312","42 CFR §418.104(a)(4)"],"surveyorAsks":["Who did the governing body appoint to have overall responsibility for the quality management, utilization and peer review program? Show me the appointment.","Show me the written criteria you use for each of the systematic reviews, and the results of the last review of on-call logs and complaints."],"forms":[{"ref":"GA-HSP-QA-01-A","title":"Adverse Event and Incident Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (Ga. Comp. R. & Regs. 111-8-37-.09; 42 CFR §418.58)","5. Quality Management Committee","6. Systematic Reviews and Written Criteria","7. Reporting Adverse Events and Incidents","8. Analysis and Performance Improvement Activities","9. Performance Improvement Projects","10. Hospice Quality Reporting Program","11. Annual Evaluation and Governing Body Oversight","12. Confidentiality and Peer Review","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":"ga-hospice","state":"Georgia","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}