{"ref":"LA-HH-QA-01","title":"Quality Assessment and Performance Improvement and Quarterly Clinical Record Review","category":"Quality","summary":"Sets out the Agency-wide, data-driven quality assessment and performance improvement (QAPI) program that LAC 48:I §9131 requires: quarterly evaluations made up of an overall policy and administrative review and a quarterly clinical record review, an assessment of whether the program is appropriate, adequate, effective and efficient, quarterly reports to the governing body which receives and acknowledges them (§9102.B.4), and the annual program evaluation (§9102.B.1); and, if the Agency is Medicare-certified, the program scope, data, activities, performance improvement projects and executive responsibilities in 42 CFR §484.65.","inShort":["Our quality program measures our care every quarter and fixes what is not working.","Each quarter nurses or therapists review a sample of records against our standards.","Results go to the governing body every quarter.","Report incidents and complaints so that we can see patterns and improve.","You can suggest a quality problem or project to the QAPI lead at any time."],"primaryCitation":"LAC 48:I §9131","citations":["LAC 48:I §9131","LAC 48:I §9131.A","LAC 48:I §9131.B","LAC 48:I §9102.B.1","LAC 48:I §9102.B.4","LAC 48:I §9127.A","LAC 48:I §9103.B.2.d","LAC 48:I §9105.B.2.b","LAC 48:I §9105.B.2.c"],"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)"],"surveyorAsks":["Show me the documentary evidence of your QAPI activities for each of the last four quarters.","How do you choose the records for your quarterly clinical record review, and what did the last review find?"],"forms":[{"ref":"LA-HH-QA-01-A","title":"Quarterly Clinical Record Review Tool"},{"ref":"LA-HH-QA-01-B","title":"Quarterly QAPI Report to the Governing Body"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I §9131)","5. Program Structure and Leadership","6. Quality Indicators and Data","7. Quarterly Evaluation, Part 1: Overall Policy and Administrative Review","8. Quarterly Evaluation, Part 2: Quarterly Clinical Record Review","9. Performance Improvement Activities and Projects","10. Immediate Correction of Problems That Threaten Patients","11. Reporting to the Governing Body and the Annual Evaluation","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"la-hha","state":"Louisiana","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}}