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Inspection Scope and QAPI Record Set

Inspection period is defined and matches the reviewed QAPI cycle critical (required)

QAPI committee or leadership review records are available for the selected period critical (required)

Yes No N/A

List of quality measures, dashboards, and PIPs included in the inspection

Data sources are identified for each measure or PIP critical (required)

Yes No N/A

Surveyor-ready file index or document map is present

Yes No N/A

Data Collection Design and Integrity

Each measure has a written definition, numerator, denominator, and data collection frequency critical (required)

Yes No N/A

Sampling method is documented when full-population review is not used

Yes No N/A

Data abstraction tool or worksheet is standardized across reviewers

Yes No N/A

Inter-rater review or validation of abstraction accuracy is documented

Yes No N/A

Missing data, exclusions, and late entries are tracked and explained

Yes No N/A

Trend Analysis and Performance Review

Trend charts or run charts show performance over time critical (required)

Yes No N/A

Performance is compared against a target, benchmark, or internal goal

Yes No N/A

Analysis identifies variation, recurring defects, or high-risk patterns

Yes No N/A

Root cause or contributing factor analysis is documented when performance is below target critical (required)

Yes No N/A

Leadership or QAPI committee review notes include decisions and follow-up actions

Yes No N/A

Performance Improvement Project Documentation

PIP aim statement is specific, measurable, and time-bound critical (required)

Baseline performance is documented before interventions begin critical (required)

Yes No N/A

Interventions, owners, and implementation dates are documented critical (required)

Yes No N/A

PDSA or similar improvement cycle is documented with test results

Yes No N/A

Post-intervention results are compared to baseline and aim critical (required)

Yes No N/A

Monitoring, Sustainment, and Corrective Actions

Sustainment monitoring plan is documented after initial improvement critical (required)

Yes No N/A

Ongoing monitoring frequency is appropriate to the risk and measure type

Yes No N/A

Corrective actions are assigned when performance remains below target critical (required)

Yes No N/A

Re-audit or follow-up review date is documented

Evidence of closed-loop follow-up is present for prior deficiencies

Yes No N/A

Documentation Quality and Survey Readiness

Documents are dated, version-controlled, and attributable to the correct review period critical (required)

Yes No N/A

Supporting evidence is legible and complete

Yes No N/A

Any gaps, non-conformances, or missing records are clearly explained

Yes No N/A

Inspector signature

Inspector comments and summary of findings

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Run: Hospice QAPI Data Collection and PIP Documentation Inspection

Inspection Scope and QAPI Record Set

Data Collection Design and Integrity

Trend Analysis and Performance Review

Performance Improvement Project Documentation

Monitoring, Sustainment, and Corrective Actions

Documentation Quality and Survey Readiness

Get your results