CMS SOM App. U, Tag R126

(1) The quality assessment and performance improvement program must include,

but is not limited to, measures to evaluate:

(i) Access to care.

(ii) Patient satisfaction.

(iii) Staff performance.

(iv) Complaints and grievances.

(v) Discharge planning activities.

(vi) Safety issues, including physical environment.

Interpretive Guidelines: §403.732(a)(1)

The facility must objectively evaluate the required areas. The facility must also

objectively evaluate any additional areas which they decide to include in their quality

assessment and evaluation program.

Specifically, at a minimum, the facility must define and describe quality assessment and

performance improvement activities that are appropriate for the services furnished in the

facility. CMS has not provided a specific definition of quality nor provides an outline for

what activities are appropriate to meet this standard due to the unique nature of the

RNHCI program.

Survey Procedures:

• Review the QAPI Program and any meeting minutes or other QAPI documents.

Does the QAPI program cover access to care, patient satisfaction, staff

performance, complaints/grievances, discharge planning and safety issues?

• Ask staff or management to explain how they use the results of the measures to

improve their program.