CMS SOM App. U, Tag R125

Performance Improvement

The RNHCI must develop, implement, and maintain a quality assessment and

performance improvement program.

Interpretive Guidelines: §403.732

The facility must have in place a program that has a definitive scope and which can be

used to measure, analyze, track, and improve performance. The plan should address the

full range of services offered by the facility. The Quality Assessment and Performance

Improvement (QAPI) program requires the RNHCI to take a proactive, comprehensive,

and ongoing approach to improving the quality and safety of the services it delivers. The

QAPI condition of participation presumes that RNHCIs employ a systems approach to

evaluating their systems and processes, identifying problems that have occurred or that

potentially might result from the organization’s practices and getting to root causes of

problems rather than just superficially addressing one problem at a time.

From a survey perspective, the focus of the QAPI condition of participation is not on

whether an RNHCI has any deficient practices, but rather on whether it has an effective,

ongoing system in place for identifying problematic events, policies, or practices and

taking actions to remedy problems, and then following up on these remedial actions to

determine if they were effective in improving performance and quality. QAPI programs

work best in an environment that fixes problems rather than assigning blame.

Survey Procedures:

• Review the RNHCI’s policies and procedures related to their QAPI program.

• Determine if the RNHCI has an ongoing program and quality assessment process.

• Ask leadership or staff to describe the QAPI program.