CMS SOM App. H, Tag V638

The dialysis facility must

continuously monitor its performance, take actions that result in performance

improvements, and track performance to ensure that improvements are sustained over

time.

Interpretive Guidance § 494.110(b):

To “continuously monitor” a facility’s performance requires that outcome data, achievement of

treatment goals, adverse events, infections, falls, errors, etc. be monitored as this data is

available or these events occur. Tracking and trending, analysis of root causes, development of

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improvement plans, implementation of those plans, evaluation of the success of the plan, and

revision of the plan should occur as indicated.

Once improvement is made, the facility must have a mechanism to ensure that improvement is

sustained. This could include practice audits, review of records, or repeat patient satisfaction

surveys, etc.

The medical director should continuously communicate with the governing body about the status

of QAPI activities, particularly when resources are required to address program improvements.

See V756. If the medical director is a part of the governing body, there should be some evidence

they provide information to members who do not participate in the QAPI meetings. The minutes

of the governing body or the minutes of the QAPI committee should demonstrate communication

between the governing body and the medical director.

Refer to V756 for the requirements related to the responsibilities of the governing body for

QAPI.