Quality Assessment and Performance Improvement and Quarterly Clinical Record Review
Sets up the Agency’s quality assessment and performance improvement (QAPI) program and the Pennsylvania clinical record reviews: a review at least quarterly of a sample of active and closed records, covering direct services and services under arrangement, and a continuing review of each patient’s record for every 60-day period of care (28 Pa. Code §601.22(d)). If the Agency is Medicare-certified, the program also meets every element of 42 CFR §484.65; the Agency runs it for every patient either way.
About this policy
- Policy number
- PA-HH-QA-01
- Version
- 1.0
- Main rule
- 42 CFR §484.65
- Library
- Pennsylvania home health · 56 policies
- Category
- Quality
- Sections
- 18
In short
- At least every quarter, nurses and therapists review a sample of active and closed records to check that our policies are followed.
- Every 60 days each patient’s record is reviewed to decide whether the plan of treatment is right and care should continue.
- We track falls, medication errors, hospital visits, infections and complaints to find ways to improve.
- If you see something that puts a patient at risk, tell the supervising nurse at once; it will be fixed right away.
- You may be asked to help with an improvement project. Your ideas are welcome.
What's inside
18 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §484.65)
- 5. The QAPI Committee and Meetings
- 6. Quarterly Clinical Record Review
- 7. Continuing 60-Day Review of Each Patient
- 8. What the Program Measures
- 9. Performance Improvement Activities and Projects
- 10. Governing Body Responsibilities
- 11. Responsibilities
- 12. Records and Compliance Monitoring
- 13. Staff Training
- 14. References
- 15. Related Policies and Forms
- 16. Approval
- 17. Revision History
An inspector may ask
- Show me your last four quarterly clinical record reviews. Who did them, how many records, and were services under arrangement included?
- How do you review each patient’s record every 60 days to decide whether the plan of treatment is adequate and care should continue?
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