{"ref":"NC-HSP-QA-01","title":"Annual Agency Evaluation and Quality Assessment and Performance Improvement","category":"Quality","summary":"Sets out the comprehensive evaluation of the whole hospice program that North Carolina requires at least once a year (all policies and procedures and a medical record review, with the evaluators' names and qualifications, criteria, methods and actions documented), and the ongoing, data-driven quality assessment and performance improvement (QAPI) program, adverse event tracking, performance improvement projects and Hospice Quality Reporting Program data (HOPE and Hospice CAHPS) required of a Medicare-certified hospice.","inShort":["Each year the Agency evaluates its whole program: every policy, a sample of medical records, and the quality of care.","The evaluation records who did it, their qualifications, the criteria and methods used, and what the Agency changed.","Records taken out for the evaluation go on the sign-out log and come back within five working days.","The quality program tracks comfort, timeliness, safety, complaints and family survey results every month.","Report incidents and collect data accurately: the numbers you enter drive the improvements the team makes."],"primaryCitation":"10A NCAC 13K .1001","citations":["10A NCAC 13K .0301(a)(9)","10A NCAC 13K .1001","10A NCAC 13K .0902(c), (d)","10A NCAC 13K .0505(c)","10A NCAC 13K .0303","G.S. 131E-202(a)(5)"],"federalCitations":["42 CFR §418.58","42 CFR §418.312","42 CFR §418.306(b)(2)","42 CFR §418.54(e)"],"surveyorAsks":["Show me your last annual evaluation. Who carried it out, what were their qualifications, and what did you change as a result?","Which policies did the evaluation review? Did it include a medical record review?"],"forms":[{"ref":"NC-HSP-QA-01-A","title":"Annual Agency Evaluation Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13K .1001)","5. The Annual Agency Evaluation","5.1 The evaluation plan and the evaluators","5.2 What the evaluation reviews","5.3 Criteria and methods","5.4 Records removed for the evaluation","5.5 Documenting the evaluation and acting on it","6. The QAPI Program","6.1 Indicators the Agency tracks","6.2 Performance improvement activities and projects","6.3 The quality committee","7. Hospice Quality Reporting Program (if Medicare-certified)","8. Governing Body Oversight","9. Responsibilities","10. Records and Compliance Monitoring","11. Staff Training","12. References","13. Related Policies and Forms","14. Approval","15. Revision History"],"version":"1.0","sample":false,"pack":"nc-hospice","state":"North Carolina","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}}