US · guidance
CMS SOM App. U, Tag R128
(3) The RNHCI must set priorities for performance improvement, considering the
prevalence of and severity of identified problems
Interpretive Guidelines: §403.732(a)(3)
The RNHCI must evaluate and track its performance improvement activities. For
instance, if problems are identified in a specific care area, whether access to care;
patient satisfaction; staff performance; discharge planning or safety issues; or if there is
an influx in complaints and grievances, the RNHCI QAPI program should set priorities
to address the concerns. The QAPI program is intended to evaluate quality and
performance and the RNHCI’s system of addressing quality concerns to better improve
outcomes for the patients, staff and overall organization.
Survey Procedures:
• Are RNHCI improvement priorities based on problems identified and is
performance improvement realistic or achievable based on the prevalence and
severity of the problem?
• Are priorities specific to identified problems with timeline for measuring each
objective?
• Are there demonstrable steps toward improvement?
History
Rev. 239; Issued: 04-24-26; Effective: 04-24-26; Implementation: 04-24-26
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
6206fe608a7d6b8da358ca86d46f4bef9edaf7290dd7e12d0060af3cd7d731e7
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