{"ref":"MO-HSP-QA-01","title":"Quality Assessment and Performance Improvement","category":"Quality","summary":"Sets out the Agency's written quality assessment and performance improvement (QAPI) plan: its goals and objectives, the person responsible for the program, the designated group that reviews it, what is measured in every service (including contracted services), how problems are resolved and corrective actions documented and checked for effect, how adverse events are tracked, how performance improvement projects are run, and how the governing body reviews and approves the plan at least once a year as 19 CSR 30-35.010(2)(N) requires.","inShort":["The Agency follows a written quality plan every year. Lee Sample runs it.","Report every incident, near miss and complaint. That data is how problems are found.","When a problem is found, a fix is chosen, written down, and checked again to see if it worked.","You may be asked to help collect data or join an improvement project. Your ideas count.","The governing body reviews the whole plan at least once a year and approves the next one."],"primaryCitation":"19 CSR 30-35.010(2)(N)","citations":["19 CSR 30-35.010(2)(N)","19 CSR 30-35.010(2)(A)1","19 CSR 30-35.010(1)(J)1","19 CSR 30-35.010(2)(J)1","13 CSR 70-50.010(7)(D)"],"federalCitations":["42 CFR §418.58","42 CFR §418.100(b)","42 CFR §418.108(d)"],"surveyorAsks":["Show me your written QAPI plan. Who is the person responsible for the program, and where does the plan say so?","Show me the governing body minutes for the last two years where the QAPI plan and activities were reviewed and approved."],"forms":[{"ref":"MO-HSP-QA-01-A","title":"Annual QAPI Plan and Governing Body Review"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (19 CSR 30-35.010(2)(N))","5. The Written QAPI Plan","6. The QAPI Committee","7. What Is Measured","8. Collecting and Analyzing Data","9. Method for Resolving Identified Problems","10. Adverse Events","11. Performance Improvement Projects","12. Governing Body Review","13. Confidentiality of QAPI Work","14. Responsibilities","15. Records and Compliance Monitoring","16. Staff Training","17. References","18. Related Policies and Forms","19. Approval","20. Revision History"],"version":"1.0","sample":false,"pack":"mo-hospice","state":"Missouri","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}}