QAPI Program Utilization_Manual

POLICY AND PROCEDURES QUALITY ASSURANCE (QAPI) Our quality assurance program (QAPI) is to assure that: 1. Our home health agency accepts patients whose home health service needs can be met by our home health agency 2. Case assignment and management is appropriate, adequate, and consistent with the plan of care, medical regimen and patient needs. Plans of care are individualized based on the patient’s needs, strengths, limitations and goals.; 3. Nursing and other services provided to the patient are coordinated, appropriate, adequate, and consistent with plans of care. 4. All services and outcomes are completely and legibly documented, dated and signed in the clinical service record; 5. The home health agency’s policies and procedures are followed; 6. Confidentiality of patient data is maintained; and 7. Findings of the quality assurance program are used to improve services. 8. Our program shall include at least quarterly, documentation of the review of the care and services of a 10 % sample of both active and closed clinical records by the Director of Nursing, Clinical Manager or his or her delegate. The Director of Nursing, Clinical Manager assumes overall responsibility for the quality assurance program. Procedure: 1. The Director of Nursing, Clinical Manager/Nurse Supervisor shall personally assign cases to nurses in a manner which reflects high professionalism and prudence. A nurse must be well suited to a case before he/she is assigned to the case. 2. Any assignment of a nurse to a case will be followed by a biweekly review by the Direct of Nursing/Nurse Supervisor to ensure that all patient care plans, medical regimens and patient needs are met. 3. The Director of Nursing, Clinical Manager/Nurse Supervisor shall conduct a yearly survey of current nursing practices by other institutions (hospitals and agencies) and compare such practices with our practices to ascertain that our practices are in line with community health nursing standards. Also, Health regulations shall be adhered to and an annual report shall be rendered to the Administrator. 4. It shall be the duty of the Nursing Director to ensure that services provided to the patients are coordinated. LPN assigned to individual cases will be visited (unannounced) at least once every month to ensure that practices are uniform. 5. The RN, Therapist or LPN assigned to a case shall ensure that all services and outcomes are completely and legibly documented, dated and signed in the clinical service record. All data sheets (flow chart, drugs administration, incident report chart, etc.) shall be recorded accordingly, and the signatures of both the nurse(s) in charge of the case and the Director of Nursing, Clinical Manager/Nurse Supervisor shall appear on each record. 6. Every nurse/therapist/aide shall ensure that patient confidentiality is maintained. The patient shall be encouraged to make comments (positive or negative) directly to the office concerning his/her care. On each visit by the Nursing Director/Nurse Supervisor, she (the Nursing Director/Nurse Supervisor) shall remember to Patient this Policy. 7. It shall be the policy of our Agency to conduct a yearly evaluation of the quality of work of all nursing and non-nursing employees. The Nursing Director, Clinical Manager/Nurse Supervisor evaluate all nursing employees. Non-nursing employees shall be evaluated by the Administrator, who will also may co- sign all evaluations. 8. Our Agency shall conduct a quarterly review of all quality assurance reports with a view to maintaining current services or improving upon them. Results of quality assurance activities will be deliberated upon by staff members at their three-monthly meetings, and all recommendations will be acted upon as necessary to improve services. 12