[Company Name]
[Address]
Tel No: (999)‐999‐9999 | Fax: (999)‐999‐9999 | Email: [email protected]
ANNUAL QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI)
# of Charts
Process Areas to Evaluate Evaluation Items Reviewed Rating (1-10) Goal (1-10) Goal Met? Comments
Did staff who performed visits undergo
basic infection control training?
Infection Control Training of Staff
Did staff have appropriate infection
control supplies or equipment?
Infection Control Were staff provided with COVID‐19
specific infection control procedures?
COVID‐19 Infection Control Procedures Were patients and/or patient's family
informed about COVID‐19 infection control
protocols?
Was there a plan of care received with the
documentation submitted?
Plan of Care
Does the plan of care cover the dates
service billed on the claim?
Is the face to face encounter
documentation submitted in the medical
record?
Face to Face
Documentation Is the face to face encounter within 90
days prior to or 30 days after the start of
care?
Does the order written on the plan of care
cover all physical therapy visit(s) billed or
Therapy Services are there additional orders?
Are the PT orders signed by the physician,
dated and legible?
When a referral is provided does the
intake process occur within 48 hours?
When a patient is admitted for home
Admission
health is the chart created, SOC plotted,
referral document uploaded, patient's
medical history uploaded?
When a physician's order is created is it
Intake Process sent out by fax or mail to the
physician/pcp within 48 hours from date
created?
Order Tracking When a physician's order is created and
sent by fax or mail to the physician (pcp)
does the intake coordinator track if it has
been returned with a signature within 7
days?
