{"ref":"LA-HSP-QA-01","title":"Quality Assessment and Performance Improvement","category":"Quality","summary":"Sets up the Agency’s quality assessment and performance improvement program under LAC 48:I §8239 and, if Medicare-certified, 42 CFR §418.58: governing body leadership and the named QAPI lead, the committee, the required contents of the written plan, the data Chapter 82 requires, standing indicators for Louisiana time frames, incident and adverse event reporting, improvement projects, corrective action, resource use, quality reporting, and the annual plan review.","inShort":["Our quality program checks all care: at home, in facilities, in the inpatient unit and by contractors. Lee Sample leads it.","Report any fall, medication error, injury, near miss or other incident to your supervisor at once, and complete Form LA-HSP-QA-01-A before the end of your shift.","Abuse, neglect or exploitation is not an ordinary incident: report it to the Administrator immediately and follow Policy LA-HSP-ANE-01.","Good-faith reports are welcome. We look for causes, fix systems and share what we learn.","The written quality plan is reviewed at least every year, and staff hear the results and the new goals."],"primaryCitation":"LAC 48:I §8239","citations":["LAC 48:I §8239","LAC 48:I §8217.F.3.b","LAC 48:I §8217.E.2.c, e","LAC 48:I §8217.O.2","LAC 48:I §8217.Q.5","LAC 48:I §8219.C.1","LAC 48:I §8221.B","LAC 48:I §8235.D.1.g","LAC 48:I §8235.D.3.b","LAC 48:I §8257.F.4.h"],"federalCitations":["42 CFR §418.58","42 CFR §418.54(e)","42 CFR §418.78(e)","42 CFR §418.108(d)","42 CFR §418.306(b)","42 CFR §418.312"],"surveyorAsks":["Show me your written QAPI plan and tell me who is responsible for the program.","When was the plan last reviewed, and what did the governing body approve?"],"forms":[{"ref":"LA-HSP-QA-01-A","title":"Incident and Adverse Event Report"},{"ref":"LA-HSP-QA-01-B","title":"Annual QAPI Plan Review"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I §8239)","5. Leadership","6. The QAPI Committee","7. The Written QAPI Plan","8. Data the Agency Collects","9. Indicators the Agency Tracks","10. Incidents and Adverse Patient Events","11. Performance Improvement Projects","12. Corrective Action and Checking That It Worked","13. Use of Services, Facilities and Staff","14. Hospice Quality Reporting Program (if Medicare-certified)","15. Annual Review of the Plan","16. Responsibilities","17. Records and Compliance Monitoring","18. Staff Training","19. References","20. Related Policies and Forms","21. Approval","22. Revision History"],"version":"1.0","sample":false,"pack":"la-hospice","state":"Louisiana","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}}