26 Tex. Admin. Code § 558.287 - Quality Assessment and Performance Improvement
(a) Quality Assessment and Performance
Improvement (QAPI) Program.
(1) An agency
must maintain a QAPI Program that is implemented by a QAPI Committee. The QAPI
Program must be ongoing, focused on client outcomes that are measurable, and
have a written plan of implementation. The QAPI Committee must review and
update or revise the plan of implementation at least once within a calendar
year, or more often if needed. The QAPI Program must include:
(A) a system that measures significant
outcomes for optimal care. The QAPI Committee must use the measures in the care
planning and coordination of services and events. The measures must include the
following as appropriate for the scope of services provided by the agency:
(i) an analysis of a representative sample of
services furnished to clients contained in both active and closed
records;
(ii) a review of:
(I) negative client care outcomes;
(II) complaints and incidents of
unprofessional conduct by licensed staff and misconduct by unlicensed
staff;
(III) infection control
activities;
(IV) medication
administration and errors; and
(V)
effectiveness and safety of all services provided, including:
(-a-) the competency of the agency's clinical
staff;
(-b-) the promptness of
service delivery; and
(-c-) the
appropriateness of the agency's responses to client complaints and
incidents;
(iii) a determination that services have been
performed as outlined in the individualized service plan, care plan, or plan of
care; and
(iv) an analysis of
client complaint and satisfaction survey data; and
(B) an annual evaluation of the total
operation, including services provided under contract or arrangement.
(i) An agency must use the evaluation to
correct identified problems and, if necessary, to revise policies.
(ii) An agency must document corrective
action to ensure that improvements are sustained over time.
(2) An agency must
immediately correct identified problems that directly or potentially threaten
the client care and safety.
(3)
QAPI documents must be kept confidential and be made available to HHSC staff
upon request.
(b) QAPI
Committee membership. At a minimum, the QAPI Committee must consist of:
(1) the administrator;
(2) the supervising nurse or therapist, or
the supervisor of an agency licensed to provide personal assistance services;
and
(3) an individual representing
the scope of services provided by the agency.
(c) Frequency of QAPI Committee meeting. The
QAPI Committee must meet twice a year or more often if needed.
Notes
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