Turning Audits into Action: How to Integrate TPE and ADR Findings into Your Hospice QAPI Program

A Targeted Probe and Educate (TPE) review or Additional Documentation Request (ADR) can feel like a disruption—but it’s also a valuable diagnostic tool. These reviews reveal the gaps in your documentation, care planning, and interdisciplinary consistency—all areas that your QAPI (Quality Assurance and Performance Improvement) program is designed to address.

The best hospice agencies don’t just respond to audits—they use them to drive improvement.

Through hospice consulting, we help agencies take audit findings and transform them into structured QAPI initiatives that not only meet compliance expectations but build long-term clinical and operational strength.

Here’s how your agency can turn audit stress into lasting quality improvements.

🧾 What CMS Wants to See After a Review

Whether it's a TPE, ADR, or survey deficiency, CMS expects your response to include:

• A clear explanation of the issue

• Corrective actions taken (not just promises)

• Education or policy updates implemented

• A monitoring plan to prevent recurrence

This makes your QAPI program the perfect container for audit follow-up.

🧠 Why QAPI Integration Matters

Too many agencies fix audit findings “off the books”—making minor adjustments without tracking their effectiveness. But that leaves you vulnerable to repeat mistakes and no data to prove you’ve improved.

QAPI provides:

✅ Structure

✅ Accountability

✅ Measurable follow-through

And when done right, it turns every audit into a performance boost—not a penalty.

✅ How to Turn Audit Findings into QAPI Projects

1. Start with a Root Cause Analysis

Before launching a Performance Improvement Project (PIP), dig into why the issue happened:

• Was it a knowledge gap?

• A workflow breakdown?

• A documentation policy that needs revision?

• Poor communication between disciplines?

🎯 Consulting Tip: Bring together compliance, clinical, intake, and leadership for a 30-minute post-audit debrief.

2. Choose a QAPI Priority Area

Use audit results to identify which CMS focus area is most impacted:

• ⏱️ Timeliness of documentation

• 📝 Eligibility and physician narrative quality

• 💊 Medication reconciliation

• 👥 Interdisciplinary coordination

• 📈 Patient outcomes and symptom management

📌 Tip: Make this your QAPI focus for the next quarter or until resolved.

3. Develop a Targeted PIP (Performance Improvement Project)

Your PIP should include:

• A specific goal (e.g., “Reduce narrative documentation errors by 50% in 60 days”)

• Action steps (training, audit tools, policy updates)

• Assigned roles

• Monitoring tools (chart audits, spot checks, EMR reports)

• A timeline for evaluation

📋 Bonus: Document it clearly in your QAPI minutes for surveyors to see.

4. Educate and Re-Educate Staff

Use audit findings to reinforce best practices:

• Host a documentation refresher

• Review examples of compliant vs. non-compliant charting

• Add audit-based scenarios to in-service training

• Ensure education is documented in personnel files

🎯 Outcome: Staff understand not just what to do—but why it matters.

5. Monitor and Measure the Impact

Your QAPI program must show whether the issue improved. Track:

• Denial rates

• Documentation accuracy scores

• Compliance with care plan updates

• Progress in achieving your PIP goals

📊 Tip: Report on this monthly in your QAPI meetings until complete.

6. Build It Into Ongoing Risk Monitoring

Once the issue is resolved, prevent recurrence by:

• Adding key items to your regular chart audits

• Monitoring high-risk diagnoses or recertifications

• Using dashboards or checklists to reinforce habits

🛡️ Your QAPI process becomes the guardrail between patient care and compliance exposure.

---

💡 Conclusion

An audit might feel like a setback—but it’s also a spotlight on your improvement opportunities. By integrating audit findings into your QAPI program, your hospice agency shows that it doesn't just respond to problems—it learns, grows, and leads.

Hospice consultants can support this process with structured audit analysis, QAPI coaching, and project planning to turn “survey season” into an ongoing culture of improvement.

---

💬 Want help turning audit findings into measurable QAPI success? Our Hospice Consulting team helps agencies connect compliance, documentation, and clinical workflows into sustainable, survey-ready quality programs.