Pursuant to section
400.610(2),
F.S., each hospice must appoint a committee which must develop, document and
implement a comprehensive quality assurance and utilization review plan, also
referred to as a quality assessment and performance improvement plan. The
QAUR/QAPI plan must be in accordance with quality assessment and performance
improvement (QAPI) standards incorporated within the Medicare Conditions for
Participation, 42 C.F.R., Part 418, and must include goals and objectives,
provisions for identifying and resolving problems, methods for evaluating the
quality and appropriateness of care, and the effectiveness of actions taken to
resolve identified problems. The QAUR/QAPI plan must establish a process for
revising policies, procedures and practices when reviews have identified
problems. The QAUR/QAPI committee must review the QAUR/QAPI plan and report
findings and recommendations to the governing body annually. Dated and signed
minutes of those meetings of the governing body at which QAUR/QAPI findings and
recommendations are presented must be kept in an administrative file.
(1) The QAUR/QAPI committee must be composed
of individuals who are trained, qualified, supervised and supported by review
procedures and written criteria related to treatment outcomes. These review
procedures and written criteria must be established with involvement from
physicians, and shall be evaluated and updated annually by the QAUR/QAPI
committee.
(2) An incident or
accident report shall be required in every instance of error in treatment,
adverse reaction to treatment or medication, or injury to the patient. All of
these incident or accident reports shall be reviewed by the QAUR/QAPI
committee.
(3) The QAUR/QAPI
committee must audit patient records, including interdisciplinary care records,
on a regular and periodic basis. All records must be stored in secured areas to
protect patient confidentiality.
(a) Active
patient records shall be kept at the main office, a satellite office, a hospice
residential facility or a hospice inpatient facility.
(b) The master record may be moved to storage
in a secure and accessible location after termination of bereavement services
or a minimum of one year after the patient's death.
(4) The QAUR/QAPI committee shall assist the
administrator in developing, documenting and implementing a formal training and
orientation program for individuals conducting utilization review
activities.
(5) Activities
undertaken by the QAUR/QAPI committee must demonstrate a systematic collection,
review, and evaluation of information and must result in proposed actions to
correct any identified problems. The information used by the QAUR/QAPI
committee must include:
(a) Care provided in
alternate settings and by contracted entities;
(b) Services provided by professional and
volunteer staff;
(c) Evaluations by
the patient and the patient's family of care provided by the hospice;
(d) Incident reports;
(e) Complaints received from patients and
their families;
(f) High-risk,
high-volume and problem-prone activities that would have a significant impact
on patients, staff or the organization, even if adverse incidents occur
infrequently. For example, high-risk activities may include review and
evaluation of protocols for containment of communicable diseases, emergency
evacuations and continuity of operations; high-volume activities might include
collection of information regarding administration of medications; lastly,
identifying problem-prone activities might include deterioration or malfunction
of equipment, including security of information systems, disposal of
contaminated materials or other bio-medical waste; and,
(g) Appropriateness of team services and
levels of care measured by whether:
1. The
plan of care was directly related to the identified physical and psychosocial
needs of the patient and the patient's family;
2. Services, medications and treatments
prescribed were in accordance with the current hospice plan of care; and,
3. The hospice care was primarily
a home-care program that utilized inpatient hospice care on a short-term or
respite basis only.
(6) The QAUR/QAPI committee shall
periodically review the accessibility of hospice services and the quality of
those services.
(7) The QAUR/QAPI
committee shall make recommendations to the administrator and the governing
body for resolving identified problems and for improving patient and family
care.
