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Annual Program Evaluation and Quality Improvement

Sets out the comprehensive evaluation of the Agency's total operation that the governing body or its designee must carry out every year under 10A NCAC 13J .1004: the policy and administration review of each required topic, the six data items the rule lists, how findings are used to fix problems and revise policies, and the required documentation of evaluators, criteria, methods and actions. It also sets up the Agency's ongoing quality improvement program, with quarterly quality indicators, and, for agencies serving NC Medicaid personal care services beneficiaries, the Policy 3L quality improvement plan updated at least quarterly, the annual written satisfaction survey and the attestation due by December 31.

Preview: full text with a package
About this policy
Policy number
NC-HC-QA-01
Version
1.0
Main rule
10A NCAC 13J .1004(a)
Library
North Carolina home care · 50 policies
Category
Quality
Sections
19

In short

  • Every year the Agency checks how well all of its services worked, using real data and records.
  • The Agency also tracks quality every quarter: supervisory visits, missed visits, complaints, incidents and training.
  • Your notes, service records and reports are the evidence. Keep them accurate and on time.
  • Clients get a satisfaction survey at least once a year. Do not collect or read a client's survey yourself.
  • Problems found lead to changes. Your supervisor will tell you what changes and why.

What's inside

19 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (10A NCAC 13J .1004(a))
  • 5. Who Carries Out the Evaluation
  • 6. Policy and Administration Review
  • 7. Data Assessed
  • 8. Quality Improvement Program During the Year
  • 9. NC Medicaid Personal Care Services
  • 10. Satisfaction Survey
  • 11. Using the Findings
  • 12. Responsibilities
  • 13. Records and Compliance Monitoring
  • 14. Staff Training
  • 15. References
  • 16. Related Policies and Forms
  • 17. Approval
  • 18. Revision History

An inspector may ask

  • Show me your last annual program evaluation. Who carried it out, what were their qualifications, and what criteria and methods did they use?
  • What did the evaluation find about clients you did not accept and why clients were discharged?

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