QAPI Program Utilization_Manual

POLICY/PROCEDURE FOR C LINICAL RECORD REVIEW QUALITY ASSURANCE (QAPI COMMITTEE) Clinical records are systematically reviewed (by a group of health professionals, representative of the scope of care and services provided by our Agency), review a sample of both active and closed records, on a quarterly basis to assess appropriateness and adequacy of care and services provided as well as to ensure compliance with established policies regarding care delivery and professional standards of practice. The QAPI (Clinical Record Review) Committee will met quarterly to analysis the QAPI procedures, and the quality of service provided, a report will be submitted to our Board of Directors, on each meeting. PROCEDURE: • A random sample of clinical records for the Home Health programs is reviewed on a quarterly basis. • Selection includes 10% of each program’s annual unduplicated admissions with a maximum of 120 sample records per year. • Record selection includes representation of all disciplines providing care, diagnostic categories, lengths of stay and discharged records. • Record reviews for clinic services include a random sample of 5% of the current active caseload as applicable • Reviews are based on specific criteria and include: Services rendered, following established agency policy, Plan of care compliance, Need for continued care, reviews & documented. It is the policy of our Agency to perform monthly chart reviews/audits by our QAPI staff, on all active patients, as well as a review of nurses notes as they are turned into the agency. Q.A./DON, Clinical Manager reviews chart/notes for completeness and ability to bill. The following areas are reviewed by Quality Assurance: Clinical notes REVIEW: Therapy & Nurse’s skill services and procedures, Patients vital signs, pain management, Assessment Procedure, Application of Medication, Wound status and sizes, procedures, Progress toward goals, homebound status, Discharge Planning, If problem is noted, contact with, M.D./DON, Clinical Manager/Supervisor and end result of contact END EPISODE CHART REVIEW: Frequency/Assessments/OASIS, Supervisory visits (LPN & HHA, PTA, OTA), Team Conferences/Communications Notes, 485/verbal orders/Reinstatement complete and timely signed, Partial discharge when applicable, Complete discharge when applicable, Medical Update Completeness/60 days Summary Report, Explanation of any missed visit/Case Conferences, Reason and order for any emergency visits, Supplies (if appropriate) 19