Annual Agency Evaluation and Quality Assessment and Performance Improvement
Sets out the comprehensive evaluation of the whole hospice program that North Carolina requires at least once a year (all policies and procedures and a medical record review, with the evaluators' names and qualifications, criteria, methods and actions documented), and the ongoing, data-driven quality assessment and performance improvement (QAPI) program, adverse event tracking, performance improvement projects and Hospice Quality Reporting Program data (HOPE and Hospice CAHPS) required of a Medicare-certified hospice.
About this policy
- Policy number
- NC-HSP-QA-01
- Version
- 1.0
- Main rule
- 10A NCAC 13K .1001
- Library
- North Carolina hospice · 60 policies
- Category
- Quality
- Sections
- 24
In short
- Each year the Agency evaluates its whole program: every policy, a sample of medical records, and the quality of care.
- The evaluation records who did it, their qualifications, the criteria and methods used, and what the Agency changed.
- Records taken out for the evaluation go on the sign-out log and come back within five working days.
- The quality program tracks comfort, timeliness, safety, complaints and family survey results every month.
- Report incidents and collect data accurately: the numbers you enter drive the improvements the team makes.
What's inside
24 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (10A NCAC 13K .1001)
- 5. The Annual Agency Evaluation
- 5.1 The evaluation plan and the evaluators
- 5.2 What the evaluation reviews
- 5.3 Criteria and methods
- 5.4 Records removed for the evaluation
- 5.5 Documenting the evaluation and acting on it
- 6. The QAPI Program
- 6.1 Indicators the Agency tracks
- 6.2 Performance improvement activities and projects
- 6.3 The quality committee
- 7. Hospice Quality Reporting Program (if Medicare-certified)
- 8. Governing Body Oversight
- 9. Responsibilities
- 10. Records and Compliance Monitoring
- 11. Staff Training
- 12. References
- 13. Related Policies and Forms
- 14. Approval
- 15. Revision History
An inspector may ask
- Show me your last annual evaluation. Who carried it out, what were their qualifications, and what did you change as a result?
- Which policies did the evaluation review? Did it include a medical record review?
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