QAPI Program Utilization_Manual

COMPLIANCE PROGRAM QUARTERLY REPORT, Year ________ 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Compliance Program : Regular Compliance Program education and training completed for the Agency staff A process in place, to receive complaints and to protect the anonymity of complainants and to protect whistle blowers from retaliation A system in place to respond to allegations of improper/illegal activities and to enforce disciplinary actions against employees who have violated internal compliance Agency in Compliance of Local, State and Federal regulations. Agency in Compliance of Accreditation standards if applicable Agency use audits and other techniques to monitor compliance Investigation and correction of system problems and development of policies relating to retention of sanctioned individuals in place Internal billing system is integrated with the clinical system that processes and tracks MD orders, Nurses Notes, and Schedules. Bills are not processed unless that Verbal and all orders are signed. Utilization review reports completed as required Staff were Agency Identification badges HIPAA privacy guidelines followed at all times and agency activities Agency’s Personnel Policy following at all time Value Base Purchase program compliance, if applicable Prevention program in place, vaccination program, following CDC guidelines Emergency/Disaster plan in place, annually revised, submitted to Community agencies Other: _______________________________________________________________________________________ Patient’s Care: Clinical procedures, while rendering patient’s care following at all time Infection Prevention program in place, Handwashing improvement program, followed, compliance analyzed Fall prevention program in place, followed by our staff Patient, staff Educational, training program compliance Quality Assurance, Performance Improvement program in place Agency Program Evaluation in place Coordination of care in place with all involved patient’s care, including Physician, staff, outside providers Nursing, Therapy and Social services following Agency Policy & Procedures Other: _______________________________________________________________________________________ Other items: _____________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Approved by Compliance Officer/Administrator: _______________________________________________ Compliance Officer signature: ____________________________________ Date: ________________ 22