CMS SOM App. B, Tag G660

The HHA’s governing body is responsible for ensuring the following:

(1) That an ongoing program for quality improvement and patient safety is

defined, implemented, and maintained;

(2) That the HHA-wide quality assessment and performance improvement

efforts address priorities for improved quality of care and patient safety, and

that all improvement actions are evaluated for effectiveness;

(3) That clear expectations for patient safety are established, implemented,

and maintained; and

(4) That any findings of fraud or waste are appropriately addressed.

Interpretive Guidelines §484.65(e)(1)-(4)

The governing body must assume overall responsibility for ensuring that the QAPI

program reflects the complexity of the HHA and its services, involves all services

(including those provided under contract or arrangement), focuses on indicators related

to improved outcomes, and takes actions that address the HHA's performance across the

spectrum of care. Additionally, the HHA’s governing body must appropriately address

any findings of fraud or waste in order to assure that resources are appropriately used

for patient care activities and that patients are receiving the right care to meet their

needs (82 FR 4504, 4510, 4561 (Jan. 13, 2017)). If the HHA identifies or otherwise

learns of an action by an HHA employee, contractor or responsible or relevant physician

or allowed practitioner that may be illegal, the HHA should report the action to the

appropriate authorities in accordance with applicable law.

Survey Procedures §484.65(e)(1)-(4)

• Ask the HHA for information about its governing body. If there are questions

about who constitutes the HHA’s governing body, it may help to review the

information the HHA reported on its CMS Form 855A application, identifying

those individuals with ownership interest or managing control of the HHA.

• Ask to see meeting minutes or other evidence of how the governing body exercises

ongoing oversight of and accountability for the HHA’s QAPI program.