{"ref":"TX-HH-QA-01","title":"Quality Assessment and Performance Improvement (QAPI)","category":"Quality","summary":"Sets up the Agency’s data-driven quality assessment and performance improvement (QAPI) program: the QAPI Committee and how often it meets, the written plan, the measures it reviews (record reviews, adverse events, complaints, infections, medication errors, competency, timeliness, OASIS and hospitalization data), performance improvement projects, immediate correction of threats to patient safety, the annual evaluation, and the governing body’s role.","inShort":["Our QAPI program measures the quality and safety of our care and fixes problems.","Report every fall, medication error, infection, and hospitalization you learn about.","If something could hurt a patient now, tell your supervisor at once. It gets fixed right away.","You may be asked to help with an improvement project or collect data. Your input matters."],"primaryCitation":"42 CFR §484.65","citations":["26 TAC §558.287","26 TAC §558.250","26 TAC §558.285"],"federalCitations":["42 CFR §484.65","42 CFR §484.70(b)","42 CFR §484.45","42 CFR §484.105"],"surveyorAsks":["Show me your QAPI plan, when it was last reviewed, and the minutes of your last two committee meetings.","What performance improvement projects are you running, why did you choose them, and what progress have you measured?"],"forms":[{"ref":"TX-HH-QA-01-A","title":"Performance Improvement Project Charter"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.65; 26 TAC §558.287)","5. The QAPI Committee","6. What the Program Measures","7. Performance Improvement Activities and Projects","8. Annual Evaluation of the Total Operation","9. Immediate Correction","10. Governing Body Responsibilities (42 CFR §484.65(e))","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":"tx-lhhs","state":"Texas","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 Home Health Agency","legalName":"Sample Home Health Agency, LLC","logo":null}}