Fifteen yes-or-no lines from the rule Texas surveyors cited most often in fiscal year 2024. Print it, answer it with your supervising nurse, and you know what to fix first.
In HHSC's Regulatory Services Annual Report for fiscal year 2024, §558.287(a)(1) was the most-cited violation for home health agencies and §558.287(c) was fifth.
We have a written QAPI plan of implementation. §558.287(a)(1)
The plan was reviewed and updated within this calendar year, and the review is dated. §558.287(a)(1)
Our committee has the administrator, the supervising nurse or therapist (or PAS supervisor), and someone representing our scope of services. §558.287(b)
The committee met at least twice in the last 12 months. §558.287(c)
The minutes show who attended, what data was reviewed, what was found and what was done. §558.287(c)
We review a representative sample of active and closed client records on a set schedule. §558.287(a)(1)(A)(i)
Each sampled record is checked against the ISP, care plan or plan of care. §558.287(a)(1)(A)(iii)
Negative client outcomes are logged and reviewed as a trend, not one at a time. §558.287(a)(1)(A)(ii)(I)
Complaints and staff-conduct incidents are logged, investigated on time and reviewed by the committee. §558.287(a)(1)(A)(ii)(II); §558.250
Client infections are documented with the §558.285 fields and reviewed by the committee. §558.287(a)(1)(A)(ii)(III)
Medication administration and errors are tracked, if we administer medications. §558.287(a)(1)(A)(ii)(IV)
We measure staff competency, promptness of service delivery and how we respond to complaints and incidents. §558.287(a)(1)(A)(ii)(V)
We collect and analyze client satisfaction survey data. §558.287(a)(1)(A)(iv)
Problems that threaten client care or safety are corrected at once, documented, and re-checked later to show the fix lasted. §558.287(a)(2); (a)(1)(B)(ii)
We completed an annual evaluation of the total operation, including contracted or arranged services, and used it to correct problems and revise policies. §558.287(a)(1)(B)