{"ref":"PA-HSP-QA-01","title":"Quality Assessment and Performance Improvement","category":"Quality","summary":"Sets out the Agency's quality assessment and performance improvement (QAPI) program, led by the designated quality lead: what is measured, how adverse events and incidents are reported and analyzed, how performance improvement projects are chosen and documented, the governing body's annual evaluation, and the Medicare Hospice Quality Reporting Program.","inShort":["Our quality program is run by Lee Sample, Quality program lead. It measures how well we care for patients and fixes what goes wrong.","If something goes wrong or nearly goes wrong (a fall, a medication error, a missed visit, broken equipment), make the patient safe first.","Tell your supervisor the same day and complete the incident report before the end of your shift.","If you suspect abuse or neglect, also make the reports in the abuse policy right away.","Incident reports are for learning, not blame. Never write in the patient record that you made one."],"primaryCitation":"42 CFR §418.58","citations":["35 P.S. §448.806(g)(2)","28 Pa. Code §51.3(e)-(g)"],"federalCitations":["42 CFR §418.58","42 CFR §418.54(e)","42 CFR §418.60(b)","42 CFR §418.62(c)","42 CFR §418.104(a)(4)","42 CFR §418.312","42 CFR §418.306(b)"],"surveyorAsks":["Who operates your QAPI program, and where is the governing body's designation?","Show me your quality indicators and the data for the last two quarters."],"forms":[{"ref":"PA-HSP-QA-01-A","title":"Adverse Event and Incident Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §418.58)","5. Leadership and the QAPI Committee","6. What the Program Measures","7. Reporting Adverse Events and Incidents","8. Analysis and Improvement Activities","9. Performance Improvement Projects","10. Hospice Quality Reporting Program","11. Annual Evaluation and Governing Body Oversight","12. Confidentiality","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"pa-hospice","state":"Pennsylvania","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}}