CMS SOM App. B, Tag G658

Beginning January 13, 2018 HHAs must conduct performance improvement

projects.

(1) The number and scope of distinct improvement projects conducted

annually must reflect the scope, complexity, and past performance of the

HHA’s services and operations.

(2) The HHA must document the quality improvement projects undertaken,

the reasons for conducting these projects, and the measurable progress

achieved on these projects.

Interpretive Guidelines §484.65(d)

The HHA should have at least one performance improvement project either in

development, on-going or completed each calendar year.

The HHA decides, based on the QAPI program activities and data, what projects are

indicated and the priority of the projects.

Survey Procedures §484.65(d)

• Ask the HHA to show you documentation for performance improvement projects

currently underway, as well as those completed in the prior year.

• Does the HHA’s documentation indicate the rationale for undertaking each project?

Does the HHA have data indicating it had a problem in the area targeted for

improvement, or could the HHA point to recommendations from a nationally recognized

expert organization suggesting the activities?

• Does the documentation for the completed project(s) include the project’s results? If a

project was unsuccessful, ask the HHA what actions it took because of that information.

If the project was successful, ask the HHA how it is sustaining the improvement.