{"ref":"PA-HH-QA-01","title":"Quality Assessment and Performance Improvement and Quarterly Clinical Record Review","category":"Quality","summary":"Sets up the Agency’s quality assessment and performance improvement (QAPI) program and the Pennsylvania clinical record reviews: a review at least quarterly of a sample of active and closed records, covering direct services and services under arrangement, and a continuing review of each patient’s record for every 60-day period of care (28 Pa. Code §601.22(d)). If the Agency is Medicare-certified, the program also meets every element of 42 CFR §484.65; the Agency runs it for every patient either way.","inShort":["At least every quarter, nurses and therapists review a sample of active and closed records to check that our policies are followed.","Every 60 days each patient’s record is reviewed to decide whether the plan of treatment is right and care should continue.","We track falls, medication errors, hospital visits, infections and complaints to find ways to improve.","If you see something that puts a patient at risk, tell the supervising nurse at once; it will be fixed right away.","You may be asked to help with an improvement project. Your ideas are welcome."],"primaryCitation":"42 CFR §484.65","citations":["28 Pa. Code §601.21(c)","28 Pa. Code §601.22(a)","28 Pa. Code §601.22(c)","28 Pa. Code §601.22(d)"],"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)","42 CFR §484.70(b)"],"surveyorAsks":["Show me your last four quarterly clinical record reviews. Who did them, how many records, and were services under arrangement included?","How do you review each patient’s record every 60 days to decide whether the plan of treatment is adequate and care should continue?"],"forms":[{"ref":"PA-HH-QA-01-A","title":"Performance Improvement Project Charter"},{"ref":"PA-HH-QA-01-B","title":"Quarterly Clinical Record Review Tool"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.65)","5. The QAPI Committee and Meetings","6. Quarterly Clinical Record Review","7. Continuing 60-Day Review of Each Patient","8. What the Program Measures","9. Performance Improvement Activities and Projects","10. Governing Body Responsibilities","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"pa-hha","state":"Pennsylvania","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}}