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Quality Assessment and Performance Improvement

Sets up the Agency's quality assessment and performance improvement (QAPI) program: the ongoing, comprehensive, integrated self-assessment of all care, including inpatient and contracted care, that OAC 3701-19-06(D) to (G) requires, built to the federal standard in 42 CFR §418.58 (data-driven indicators, adverse event tracking, performance improvement projects and governing body responsibilities), with the Hospice Quality Reporting Program submissions that Medicare and Ohio Medicaid payment depend on and the annual evaluation of the program.

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About this policy
Policy number
OH-HSP-QA-01
Version
1.0
Main rule
OAC 3701-19-06(D)-(G)
Library
Ohio hospice · 60 policies
Category
Quality
Sections
22

In short

  • Our quality program measures all care we give or arrange, including in facilities and under contract.
  • Report every fall, medication error, injury or near miss on an incident report before the end of your shift.
  • Your visit notes and assessments feed the quality data we must send to CMS on time.
  • Ask your supervisor about the current improvement projects and how you can help.

What's inside

22 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 (OAC 3701-19-06(D)-(F); 42 CFR §418.58)
  • 5. How the Program Is Organized
  • 6. What Is Measured
  • 7. Choosing Priorities
  • 8. Adverse Events
  • 9. Performance Improvement Projects
  • 10. Using What Is Found
  • 11. Hospice Quality Reporting Program
  • 12. Non-Hospice Palliative Care Patients
  • 13. Annual Evaluation of the Program
  • 14. Reports to the Governing Body
  • 15. Responsibilities
  • 16. Records and Compliance Monitoring
  • 17. Staff Training
  • 18. References
  • 19. Related Policies and Forms
  • 20. Approval
  • 21. Revision History

An inspector may ask

  • Who operates your QAPI program, and how does the governing body oversee it?
  • Show me the indicators you track, including adverse events, and the data for the last two quarters.

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