{"ref":"NC-HH-QA-02","title":"Quality Assessment and Performance Improvement (QAPI)","category":"Quality","summary":"Establishes the Agency’s data-driven, agency-wide quality assessment and performance improvement (QAPI) program under 42 CFR §484.65, which NC Medicaid also requires: the indicators the Agency tracks, including OASIS outcomes, emergent care use, hospital admissions and adverse events; the governing body’s approval of data collection; immediate correction of problems that threaten patient safety; performance improvement projects; and how the annual evaluation and 90-day record reviews required by 10A NCAC 13J .1004 feed the program.","inShort":["Our quality program (QAPI) tracks outcomes such as hospital admissions, emergency care, falls, medication errors and infections.","Report every adverse event so it can be counted, its cause found, and steps taken to prevent it.","A problem that threatens a patient’s health or safety is corrected at once, not saved for the next meeting.","Each year the Agency runs at least one performance improvement project chosen from its data (Agency standard). You may be asked to join the team.","On-time aide supervision, plan of care reviews every 90 days, and signed verbal orders are checked every month."],"primaryCitation":"42 CFR §484.65","citations":["10A NCAC 13J .1004","10A NCAC 13J .1110(c)","10A NCAC 13J .1202(a)","10A NCAC 13J .1302(d)","NC Medicaid Clinical Coverage Policy 3A"],"federalCitations":["42 CFR §484.65","42 CFR §484.70(b)","42 CFR §484.80(h)","42 CFR §484.105(a)"],"surveyorAsks":["Show me your QAPI program. Which indicators do you track, and who approved how often the data is collected?","What performance improvement projects did you run this year, why did you choose them, and what changed?"],"forms":[{"ref":"NC-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; NC Medicaid Clinical Coverage Policy 3A)","5. Governing Body and Leadership","6. Program Scope and Data","7. Program Activities","8. Performance Improvement Projects","9. Link to the North Carolina Evaluations","10. Responsibilities","11. Records and Compliance Monitoring","12. Staff Training","13. References","14. Related Policies and Forms","15. Approval","16. Revision History"],"version":"1.0","sample":false,"pack":"nc-hha","state":"North Carolina","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}}