CMS SOM App. FC, Tag M0271

client events, including the use of restraint and seclusion; and other aspects of

performance that enable the CMHC to assess processes of care, CMHC services, and

operations.

Interpretive Guidelines §485.917(a)(2)

The review of the QAPI data verifies that the CMHC develops the individual indicators of

their particular QAPI plan and these indicators address all facility programs and services.

Indicators should be measurable to enable the CMHC to demonstrate, through the use of

objective data, that improvements have or have not taken place in: actual care outcomes;

processes of care; client satisfaction levels; CMHC operations; or other performance

indicators.

CMHCs must collect and analyze client care and administrative quality data generated

by the medical and professional/technical staffs and use those data to identify, prioritize,

implement, and evaluate performance improvement projects to improve the quality of

services furnished to CMHC clients. CMHCs are required to assess quality in all areas

of operations that might be adversely affecting patient care or CMHC services. There is

a specific requirement for CMHCs to track adverse client events (as they are defined in

CMHC policy), including the use of restraint and seclusion, and reduce their occurrence

where possible.

In order to assess compliance with the QAPI requirements and to determine the

adequacy and appropriateness of a CMHC’s QAPI program, there must be evidence of

the following:

1. The CMHC’s QAPI plan identifies individual indicators reflective of program

services;

2. Summary analysis reports are submitted to the Governing Body;

3. The names of the individuals responsible for the QAPI program;

4. The QAPI program has been implemented and is functioning including evidence

of:

a. Any regular QAPI committee meeting minutes;

b. Investigation and analysis of all sentinel and adverse events;

c. Recommendations/implementation for systemic change to prevent

recurrence of sentinel or adverse events;

d. Identified performance measures that are tracked and analyzed; and

e. Sufficient resources available to implement the CMHC’s QAPI program.