Emergency Plan
Same month every year (annually)
Complete the Agreement with another Agency. (Fax to us the information to complete/submit the Plan)
Same month every year (annually)
Complete the Agreement with another Agency. (Fax to us the information to complete/submit the Plan)
Renew License Form: 60 days before to expiration date. CLIA application form
(The templates must be updated with your discussion during preparation of your PI and QA program, and Agency's data and reality, your DON must review/approve the reports and data collection.)
Also: Please complete to be ready for new CoPs:
1) The Clinical Record review minute and support documents
2) ALL monthly/quarterly report
3) ALL Logs
DON/QA Staff: Template for Performance Improvement Data Collection/Analyzes:
QAPI Data collection (al year long) PI Monitoring Log (Quarterly)
DON: Performance Improvement Plan: Target for Improvement or Replication (quarterly)
Performance Improvement Plan (annual) PI target for improvement report Pediatric PT target for improvementMeasurable Improvement report: (DON-quarterly) Care Plan Compliance problem PI Report
Measurable improvement report Care Plan compliance Problem PI report
DON, Clinical Manager/QA: Performance Levels, Patterns, Trends, Variations: (Quarterly)
PI: Performance, Patterns, Trends PI: Performance Tracking Report
DON, Clinical Manager: OBQI Analyzes LOG (OBQI report must be analyzed by the Agency on Regular BD meeting, this log documented the review of the OBQI (Casper) reports) (Quarterly)
OBQI Analyzes Log Adverse Event (OBQI Analyzes)
QAPI REPORTS:
QA/DON/Clinical Manger: Monthly report about hospitalization, emergency care prevention (results of risk assessment)
(QAPI PROJECT)
DON: Hospitalization LOG (Must be completed monthly) Hospitalization Log
Hospitalization risk analysis: Hospitalization risk analysis Emergency care risk analysis: Emergency Care risk analysis
QAPI Project Hospitalization/Emergency Care: Hospitalization/Emergency care services risk Project
QAPI Plan-Do-Study-Act (PDSA) Hospitalization/Emergency Care PDSA
Decreasing Hospitalization, Improvement report: Decreasing hospitalization/Improvement Report
Cardio Vascular Disease Project: CVD Project CVD Plan-Do_Study (PDSA) CVD PDSA
(Complete the DC Planning control log, and have the Total DC patients with High BP)
QAPI TOOLS:
DON/QA staff: Progress Note review form Sign Up Package check up form Improve Documentation:
Progress Notes Review Form Sign Up Package Check list Prevent Conditionals Defficieny
DON/QA Staff: Chart Audit check list Q60 days (On Recert or Discharge)
Record review tool: QA Audit Form Private Duty: QA Audit Form (PD) Pediatric: QA Audit Form (Ped.)
DON/QA Staff: POC Tips POC TIPS (Orders/Goals) Prevention Conditional level defficiency Assement/POC
PANIC VALUE list: (Verify that if any parameter is out of normal limit, the patient's physician was notified)
* Please be sure to add to the 485 Goals (box 22) realistics End Point goals
* Add Hospitalization & Emergency visit risks, Patient's identified goals, care preferences
* Add Advance Directives information in details to 485 (as was collected during sign up)
PANIC VALUE (Can be customized, if changed please replace that page in your Policy Manual)
QA Staff: Verification of visits/services patients random calls (Monthly)
Monthly QA Phone Calls Patient Satisfaction Survey Patient Survey Patient Survey Summary Summary
MD Survey MD Survey
QA Staff: Performance Improvement Bar Graphic Study sample:
BAR Graphic Hospitalization Risk BAR Graphic Generic
Administrator/DON: Survey Ready Check List
Covid-19 QAPI Report (Quarterly): COVID-19 PI Report *** no longer mandatory after 05/11/2023
For use by PN System's QA Nurse only:
Consultant Report (After visit as applicable)
Disclaimer: Every template is only your guide/AGENDA to type the Minutes of your meeting, your Agency Officials must assure that the meeting occur, the quorum is acceptable, and every member had active participation in the discussion
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