QAPI stands for quality assessment and performance improvement. Every Medicare-certified home health agency must run an ongoing, agency-wide QAPI program that uses data to measure the quality and safety of its care, finds where it can do better, acts, and checks that the improvement lasts (42 CFR §484.65). The agency must keep documentary evidence of the program and be able to show that it works. Several states add quality rules of their own, such as a regular review of a sample of clinical records.
What §484.65 requires
| Part | What the rule asks | Rule |
|---|---|---|
| Scope | A program that reflects the complexity of the agency and its services, involves every service, including those under contract or arrangement, and focuses on indicators tied to better outcomes, including emergent care use, hospital admissions and readmissions | §484.65 |
| Measures | Measurable improvement in indicators where improvement leads to better health outcomes, patient safety and quality of care, and measuring, analyzing and tracking quality indicators, including adverse patient events | §484.65(a) |
| Data | Quality indicator data, including measures derived from OASIS, used to monitor the effectiveness and safety of services and to find opportunities for improvement. The governing body approves how often and in how much detail data are collected. | §484.65(b) |
| Activities | A focus on high-risk, high-volume or problem-prone areas, immediate correction of any problem that threatens patient health and safety, tracking adverse events and analyzing their causes, and checking that improvements are sustained | §484.65(c) |
| Performance improvement projects | Projects whose number and scope reflect the agency's services, complexity and past performance, each documented with the reason for it and the measurable progress achieved | §484.65(d) |
| Governing body | Makes sure the program is defined, carried out and kept up, addresses priorities for quality and patient safety, evaluates every improvement action, sets clear expectations for patient safety, and addresses any findings of fraud or waste | §484.65(e) |
Infection control belongs in QAPI as well: the agency's infection prevention and control program is an integral part of its QAPI program (42 CFR §484.70(b)). Medicare-certified agencies also report quality data, including OASIS and, where required, HHCAHPS patient survey data, through the Home Health Quality Reporting Program (42 CFR §484.245).
What a QAPI program looks like in practice
- A named lead or committee that reviews the data on a set schedule. The federal rule does not say how often, so the agency sets it, unless its state does, as the table below shows.
- A list of indicators, for example hospital admissions, emergent care visits, falls with injury, medication errors, timely start of care, missed visits and complaints.
- Incident reports that feed adverse event tracking, with the causes of serious events analyzed and preventive action taken.
- Performance improvement projects, each with a baseline, a measurable goal, the actions taken and the results.
- Written reports to the governing body, with its decisions recorded in its minutes.
What state rules add
| State | What the rule adds | Rule |
|---|---|---|
| Texas, all licensed agencies | A QAPI program run by a QAPI Committee that includes the administrator, the supervising nurse (or a supervising therapist where the agency provides only therapy) and someone representing the agency's services, with a written plan reviewed every calendar year and meetings at least twice a year | 26 TAC §558.287 |
| Florida | An ongoing quality assurance program led by the director of nursing, with a documented review at least every quarter of a sample of active and closed clinical records | Rule 59A-8.0095(2)(e), F.A.C. |
| Georgia | An overall evaluation of the agency's program at least once a year, reported to the governing body, and a review at least every quarter of a sample of active and closed clinical records, recorded in dated minutes | Rule 111-8-31-.07(8) |
| Louisiana | A quarterly QAPI program, with an overall policy and administrative review and a quarterly clinical record review, reported to the governing body | LAC 48:I §9131 |
| Pennsylvania | A yearly program evaluation and a review at least every quarter of a sample of active and closed clinical records | 28 Pa. Code §601.22(c) and (d) |
| North Carolina | A yearly evaluation of the agency's total operation and a client record review every 90 days | 10A NCAC 13J .1004 |
| California | A quality management system with a review every six months of a sample of clinical records representative of the patients' diagnoses and services, and a yearly review of overall agency functioning | 22 CCR §74742 |
| Missouri | Every licensed agency meets the federal Conditions of Participation, including §484.65, whether or not it is Medicare-certified | 19 CSR 30-26.010(1)(A) |
Each state's home health manual sets out its quality rules alongside §484.65: see all home health manuals.
Questions a surveyor may ask
- Show me your QAPI program. What indicators are you tracking and what do the data show?
- What performance improvement projects have you done this year, why did you choose them, and what changed?
- How do you track adverse events, and what did you do after the last one?
- How is the governing body involved? Who approved the frequency and detail of your data collection?
- How is infection control part of QAPI?
Next step
Every Cura Core home health manual includes a QAPI policy written to §484.65 and your state's rules. Pick your state on the home health manuals page and read three of its policies free. For the other policies a home health agency needs, see what policies are required for home health.