CMS SOM App. M, Tag L563

§418.58(b)(1) The program must use quality indicator data, including patient care,

and other relevant data, in the design of its program.

Interpretive Guidelines §418.58(b)(1)

Hospices must not limit their QAPI data collection efforts to the data collected during

patient assessments. Data collection must look beyond patient assessment data to

examine all facets of a hospice’s operation. All patient services and all activities that

may impact patient/family care should be evaluated as part of the QAPI program. This

would include but not be limited to:

• physician services,

• nursing services,

• medical social services,

• counseling services,

• clinical records,

• infection control,

• pharmaceutical services,

• durable medical equipment (DME),

• patient rights,

• administrative services,

• contract services,

• volunteers,

• hospice aide and

• adverse events.

Whatever measures the hospice chooses to assess quality should be monitored regularly

so that opportunities for improvement can be identified and prioritized. Data should be

collected in a timely manner so that measures can be reported on the schedule set up by

the hospice.