Florida Regulations 59A-38.006: Quality Assurance and Utilization Review (QAUR)/Quality Assessment and Performance Improvement (QAPI) Committee and Plan
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Pursuant to Florida Statutes § 400.610(2), 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.
Rulemaking Authority 400.605 FS. Law Implemented 400.605, 400.610 FS. History-New 5-6-82, Formerly 10A-12.10, 10A-12.010, Amended 4-27-94, Formerly 59A-2.010, Amended 6-5-97, 8-11-08, Formerly 58A-2.010, 7-1-19.
(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.
Rulemaking Authority 400.605 FS. Law Implemented 400.605, 400.610 FS. History-New 5-6-82, Formerly 10A-12.10, 10A-12.010, Amended 4-27-94, Formerly 59A-2.010, Amended 6-5-97, 8-11-08, Formerly 58A-2.010, 7-1-19.