CMS SOM App. U, Tag R127

the RNHCI includes, the RNHCI must do the following:

(i) Define quality assessment and performance improvement measures.

(ii) Describe and outline quality assessment and performance improvement

activities appropriate for the services furnished by or in the RNHCI.

(iii) Measure, analyze, and track performance that reflect care and RNHCI

processes.

(iv) Inform all patients, in writing, of the scope and responsibilities of the quality

assessment and performance improvement program.

Interpretive Guidelines: §403.732(a)(2)

The RNHCI must have policies and procedures which define their respective QAPI

program. CMS does not prescribe a particular format of the QAPI program; it provides

each RNHCI with the flexibility to develop its own program. Each program must,

however, satisfy the regulatory criteria. Additionally, the program should be ongoing and

data driven in order to properly measure, analyze and track performance. For example,

the RNHCI should consider this to mean:

• Ongoing – i.e., the program is a continuing one, not just a one-time effort.

Evidence of this would include, but is not limited to, things like collection of

quality data at regular intervals; analysis of the updated data at regular

intervals; and updated records of actions taken to address quality problems

identified in the analyses, as well as new data collection to determine if the

corrective actions were effective.

• Data-driven – i.e., the program must identify in a systematic manner what data

it will collect to measure various aspects of quality of care; the frequency of

data collection; how the data will be collected and analyzed; and evidence that

the program uses the data collected to assess quality and stimulate performance

improvement.

The RNHCI QAPI program must also have a process which informs the patient and/or

patient’s representative of the QAPI program, its scope and purpose and patients should

be able to access such information.

Survey Procedures:

• Review facility policies and procedures on the quality assessment and

performance improvement program.

• Determine if the facility has a formal method to identify issues in the facility,

which require quality assessment and performance improvement.

• Determine if the facility has a method to respond to identified issues and the

means to evaluate the response to the issues.

• Verify through interviews with staff, patients, and governing body member(s) that

the facility has established a protocol or method for addressing quality in the

facility, and those issues that the facility believes have now been resolved.

• Verify that the staff and patient know how to access that process.