QAPI Program Utilization_Manual

QA AUDIT /REVIEW FORM (PRIVATE DUTY) Patient Name/MR # : ______________________________________________________ Cert.Period : ______________ Orders: 9 POC (485) signed within 30 days , Initial order 9 POC completed, frequency, orders correctly 9 Reinstatement, Recert Order as applicable I ntervention to identify fall risks 9 Therapy Care Plan (Short-Long term goals , modalities as tolerated, therapists professional expertise ) Notes: 9 Progress Notes current in file, all disciplines 9 POC followed (aide ,PTA ?) Reporting guideline to Agency, SV, MD office documented 9 Two ID checked before services 9 Vital Signs recorded 9 Title, credentials in all notes 9 Coordination of Care with other discipline reflected 9 Medical supplies recorded 9 Additional needs are identified during patient's care, MD notified, order obtained 9 SV notes (Q14 days HHA with skill, Q60 days HHA without skill, Q30days LPN, PTA, OTA, STA) 9 Handwashing 9 Frequency of visit compliance (zero fraud tolerance) 9 Therapy staff following POC, no modality used without order 9 Infection Control, Universal Precautions stated in notes 9 Diabetic, looking for help to adm. Injection 9 Notes delivery on time to Agency (before Tuesday next week) 9 Case Conference (Q30D) 9 Team Comm. 9 Glucometer Calibration (daily)/Quality Control weekly 9 BS Log 9 BP Log 9 Non Verbal pain assessment (FLAC) 9 Get Up and Go Fall Test 9 Norton/Branden Scale 9 Procedure and Modalities, amount, freq, duration in therapy notes 9 ALF: No staff signatures, copy of Patient Contract, ALF license 9 Weekly used, signed by Patient 9 Wound Forms, pictures, addendum weekly Depression Scale PHQ-9 , if applicable 9 Admission Package Completed, 48 hrs 9 Agreement completed, no blank spaces 9 Handbook discussed with patient 9 Gloves change technique reported by SV 9 Nursing Bag procedure (CPR mask) 9 Handwashing 9 Advance Directive Information, Policy 9 Bill of Rights according Accreditation 9 Medication according accreditation 9 Initial/Admission Order 9 If patient transfer to your Agency, from another, document Patient Elected transfer 9 Pay Sources, Charge for services (already in the handbook) , Frequency completed, including in Home folder . 9 Assessment completed, 48 hrs 9 Pediatric Assessment if applicable 9 No blank spaces, answers 9 D/C addendum for therapy completed by therapy services Transfer to In-patient Facility , faxed to MD/Hospital Performance Improvement (PI Plan) Add Complaints/Grievance, Survey results (quarterly report) to PI discussion 9 Document the issues, findings, threshold and corrective actions, how PI results improve Patient Quality Car e 9 Monitor Aide, therapy services 9 Include all Incidents Report (Occurrence Report) 9 Fall prevention, interventions 9 Pain management plan in place 9 Trends for improvement or replication 9 Discharge Packages 9 Modify Order if D/C was completed before planned 9 D/C instruction 9 60 Days Summary 9 D/C summary if applicable 9 Therapy D/C addendum 9 Partial D/C if applicable Comments: Auditor Name/Title/ Signature:_______________________________________________ Date: ___________________ (faxed to MD) (www.pnsystem.com ) (faxed to MD) Missed visit report (Faxed to MD) 9 Updates Plan (Aide Plan, reviewed q60d), Mod. Orders as needed Medication re-conciliated (MD) , interaction, match 485-Profile-Home folder 9 Individualized plan, parameters to report MD , D/C planning, rehab potential G uidelines to involve fam ily /caregivers in patient’s care 9 Therapy Eval-Re-eval ( within 30 days ) (signed by MD if app. ) Agreement Addendum in all Frequency changes (Mod.Orders, ROC, Recerts) 9 D/C planning, Progress toward achieved goals documented in all notes ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 42