#10 [TIED]: Quality Assessment & Performance Improvement: 42 CFR 418.58, TAG 0560
The hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. The hospice's governing body did not ensure that the program: reflects the complexity of its organization and services; involves all hospice services (including those services furnished under contract or arrangement); focuses on indicators related to improved palliative outcomes; and takes actions to demonstrate improvement in hospice performance. The hospice failed to maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to the Centers for Medicare and Medicaid Services.
The hospice failed to maintain evidence of an on-going QAPI program. The QAPI plan was last revised on 08/01/2011 and the last QAPI meeting minutes were dated 11/05/2011.