CMS SOM App. A, Tag A-0320

If a hospital is part of a hospital system consisting of multiple separately certified hospitals

using a system governing body that is legally responsible for the conduct of two or more

hospitals, the system governing body can elect to have a unified and integrated QAPI

program for all of its member hospitals after determining that such a decision is in

accordance with all applicable State and local laws. The system governing body is

responsible and accountable for ensuring that each of its separately certified hospitals

meets all of the requirements of this section. Each separately certified hospital subject to

the system governing body must demonstrate that:

Interpretive Guidelines §482.21(f)

The hospital must have a QAPI program for the entire hospital (including all campuses, provider-based locations, satellites, remote locations, etc.). In the case of a hospital system, it is permissible

for the system to have a unified and integrated QAPI program (hereafter referred to as a “unified

and integrated QAPI”) for multiple, separately certified hospitals.

If the hospital uses a unified and integrated QAPI program that it shares with other hospitals that

are part of a multi-hospital system, the system governing body is responsible and accountable for

ensuring that each of its separately certified hospitals meets all of the requirements of §482.21. Thus,

each separately certified hospital subject to the system’s governing body must meet all of the QAPI

program requirements as outlined in the regulations at §482.21.

Survey Procedures §482.21(f)

• Surveyors assess the manner and degree of noncompliance with the standards within this

condition to determine whether there is condition-level noncompliance.